(Medicare Claims Processing Manual)

The revenue code for the appropriate treatment modality is billed (e.g., 0821 for hemodialysis).  Effective January 1, 2015, ESRD facilities are required to report on the claim the drugs identified on the consolidated billing list provided at  http://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/ESRDpayment/Consolidated_Billing.html    082X - Hemodia lysis - Outpatient or Home Dialysis - A waste removal process performed in an outpatient or home setting, necessary when the bodys own kidneys have failed.  Waste is removed directly from the blood.  Detailed revenue coding is required.  Therefore, servic es may not be summed at the zero level.   0 - General Classification  HEMO/OP OR HOME  1  Hemodialysis/Composite or other rate HEMO/COMPOSITE  2 - Home Supplies HEMO/HOME/SUPPL  3 - Home Equipment HEMO/HOME/EQUIP  4 - Maintenance 100% HEMO/HOME/100%  5 - Support Services HEMO/HOME/SUPSERV 9 - Other Hemodialysis Outpatient HEMO/HOME/OTHER   083X - Peritoneal Dialysis - Outpatient or Home - A waste removal process performed in an outpatient or home setting, necessary when the bodys own kidneys have failed.  Waste is removed indirectly by instilling a special solution into the abdomen using the peritoneal membrane as a filter .  0 - General Classification  PERITONEAL/OP OR HOME  1 - Peritoneal/Composite or other rate PERTNL/COMPOSITE  2 - Home Supplies PERTNL/HOME/SUPPL  3 - Home Equipment PERTNL/HOME/EQUIP  4 - Maintenance 100% PERTNL/HOME/100%  5 - Support Services PERTNL/HOME/SUPSERV  9 -Other Peritoneal Dialysis  PERTNL/HOME/OTHER   084X - Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient - A continuous dialysis process performed in an outpatient or home setting, which uses the patients peritoneal membrane as a dialyzer.   0 - General Classification  CAPD/OP OR HOME  1 - CAPD/Composite or other rate CAPD/COMPOSITE  2 - Home Supplies CAPD/HOM E/SUPPL  3 - Home Equipment CAPD/HOME/EQUIP  4 - Maintenance 100% CAPD/HOME/100%  5 - Support Services CAPD/HOME/SUPSERV 9 -Other CAPD Dialysis  CAPD/HOME/OTHER   085X - Continuous Cycling Peritoneal Dialysis (CCPD) - Outpatient. - A continuous dialysis process performed in an outpatient or home setting, which uses the patients peritoneal membrane as a dialyzer.   0 - General Classification  CCPD/OP OR HOME  1 - CCPD/Composite or other rate CCPD/COMPOSITE  2 - Home Supplies CCPD/HOME/SUPPL  3 - Home Equipm ent CCPD/HOME/EQUIP  4 - Maintenance 100% CCPD/HOME/100%  5 - Support Services CCPD/HOME/SUPSERV 9 -Other CCPD Dialysis  CCPD/HOME/OTHER   088X - Miscellaneous Dialysis - Charges for Dialysis services not identified elsewhere.   0 - General Classification  DAILY/MISC  1  Ultrafiltration  DAILY/ULTRAFILT  2  Home dialysis aid visit HOME DIALYSIS AID VISIT  9 -Other misc. Dialysis  DAILY/MISC/OTHER   HCPCS/Rates   All ESRD hemodialysis claims must include HCPCS 90999 on the line reporting revenue code 082x. All  AKI claims must include HCPCS G0491.  Modifiers   Modifiers are required with ESRD Billing for reporting the adequacy of dialysis and the vascular access.  For information on modifiers required for these quality measures see 50.9 of this chapter.   For info rmation on reporting modifiers applicable to the Erythropoietin Stimulating Agents refer to section 60.4 of this chapter.   Route of administration modifiers required are JA, JB and JE.   For information on reporting the AY modifier for services not related to the treatment of ESRD, see sections  60.2.1.1 -  Separately Billable ESRD Drugs  and 60.1 -  Lab Services.   For information on reporting the CG modifier for additional treatments provided without medical justification, see section 10.1 of this chapter.  Service Date   Report the line item date of service for each dialysis session and each separately payable item or service.   Service Units   Hospital -based and independent renal facilities must complete this item.  The entries quantify services by revenue catego ry, e.g., number of dialysis treatments. Units are defined as follows:   0634 -  Erythropoietin (EPO) -  Administrations, i.e., the number of times an injection of less than 10,000 units of EPO was administered.  For claims with dates of service on or after J anuary 1, 2008, facilities use the units field as a multiplier of the dosage description in the HCPCS to arrive at the dosage amount per administration.  0635 -  Erythropoietin (EPO) -  Administrations, i.e., the number of times an injection of 10,000 units or more of EPO was administered.  For claims with dates of service on or after January 1, 2008, facilities use the units field as a multiplier of the dosage description in the HCPCS to arrive at the dosage amount per administration.  082X -  (Hemodialysis) -  Sessions   083X -  (Peritoneal) -  Sessions   084X -  (CAPD)  Per Day  085X -  (CCPD)  Per Day  Effective April 1, 2007, the implementation of ESRD line item billing requires that each dialysis session be billed on a separate line.  As a result, claims with dates of service on or after April 1, 2007 should not report units greater than 1 for each dialysis revenue code line billed on the claim.   Total Charges   Hospital -based and independent renal facilities must complete this item.  Hospital- based facilities must show their customary charges that correspond to the appropriate revenue code.  They must not enter their composite or the EPO` rate as their charge. Independent facilities may enter their composite and/or EPO rates.   Neither revenue codes nor charges for services included in the composite rate may be billed separately (see 90.3 for a description).  Hospitals must maintain a log of these charges in their records for cost apportionment purposes.   Services which are provided but which are not included in the composite rate may be billed as described in sections that address those specific services.   The last revenue code entered in as 000l represents the total of all charges billed.   Principal Diagnosis Code   Hospital -based and independent renal facilities must complete this item and it should include a diagnosis of end stage renal disease for patients with ESRD. For patients with AKI see section 40 of this chapter.  Other Diagnosis Code(s)   For claims with dates of service on or after January 1, 2011 rena l dialysis facilities report the appropriate diagnosis code(s) for comorbidity conditions eligible for an adjustment.  50.3.1 - Submitting Corrected Bills  (Rev. 1, 10- 01-03)  Claimants must submit a corrected claim if any of the following apply to a previously processed claim:    A change in provider number;   A change in coinsurance involves an amount greater than $1.99; or   A change in visits (decrease or increase).   Claimants must follow procedures for submitting corrected bills in Chapter 26.  50.4 - Line Item Detail Billing and Automated Claim Adjustments (Rev. 1364, Issued:  11- 02-07: Effective:  04- 01-08; Implantation:  04- 07-08)  The implementation of line item detail billing for ESRD claims effective on April 1, 2007 requires that each service be submitted on a separate line with the appropriate line item date of service.  The Medicare standard systems perform line item date of service compare for RDFs claims with statement billing periods overlapping the statement billing period of another proc essed claim.  This prevents monthly claims from receiving overlapping edits based on the statement billing period dates but rather, only when the RDF claim has a line item that duplicates another processed claim or falls within the dates of an inpatient hospital stay.  Standard systems reject only those overlapping line items while any line items not overlapping another claim continue to process for payment.  As a result of this logic, the RDFs no longer have to submit the occurrence span code 74 on the mon thly dialysis claim when an inpatient stay occurred during the same month.  The initial line item detail billing instruction did not implement a process for rejecting services on the RDF claim overlapping an inpatient stay when the RDF claim is received before the inpatient hospital claim.  A subsequent instruction implemented for April 1, 2008 requires the Medicare Common Working File (CWF) to create an informational unsolicited response prompting the standard system to perform an automated adjustment of the processed 72x claim that contains line item dates of service that are overlapping dates of an incoming inpatient hospital claim.  The admission and discharge dates of an inpatient stay are not considered overlapping dates and may be payable to the RDF.   50.5 - Intermittent Peritoneal Dialysis (IP D) in the Facility (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  Payment for Intermittent Peritoneal Dialysis (IPD)  in the facility is subject to the same payment rules as hemodialysis.   50.6 - In-Facility Back -Up Dialysis  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)   Back -up dialysis is an in- facility dialysis treatment furnished to a home dialysis patient. Condition code 76 must appear as one  entry in Form Locators ( FLs) 24-30. The facility must explain why any in -facility backup dialysis sessions (furnished on either an inpatient or outpatient basis) are furnished to home dialysis patients who are covered under the Prospective Payment System (PPS) base rate . If a backup session is furnished because of a failure to furnish any of the required items or services, then it will be covered only to the extent of a home dialysis session and reimbursed at the facilitys  PPS base rate . If the backup dia lysis is furnished by an institution other than the home patients End Stage Renal Disease (ESRD)  facility, then the ESRD facility must assume financial liability for any cost or charge in excess of the ESRD  facilitys PPS base  rate except where the patien t is traveling away from home.    50.6.1 - Payment for In -Facility Maintenance Dialysis Sessions Furnished to Continuous Ambulatory Peritoneal Dialysis (CAPD) /Continuous Cycling Peritoneal Dialysis (CCPD  Home Dialysis Patients          (Rev. 10640, Issued:08 -06-21, Effective:09- 07-21, Implementation:09- 07-21)  Although Continuous Ambulatory Peritoneal Dialysis  (CAPD ) and Continuous Cycling Peritoneal Dialysis  (CCPD ) patients are home dialysis patients, it may be necessary at times to dialyze them in -facility as a substitute.  In this case, the total weekly reimbursement to the facility remains the same regardless of the type and frequency of in -facility dialysis involved.   In order to furnish covered CAPD services, a facility must be a Medicare approv ed ESRD facility and must meet additional standards established by CMS.   However, in rare instances an ESRD patient may require a combination of dialysis techniques, on the same day, in order to achieve satisfactory results.  In these situations, Medicare pays for both types of dialysis services furnished on the same day.  Medicare A/B MACs (A) determine the medical necessity.  In each case the A/B MAC (A) obtains medical documentation from the facility that supports the use of back- up dialysis with another  treatment modality.  If a CAPD patient frequently requires back- up sessions, the A/B MAC (A)s medical staff may request medical records to determine if this is the appropriate mode of treatment to meet medical necessity requirement for payment purposes a nd/or whether a different mode of treatment is more advantageous to the beneficiary.   50.6.2 - Payment for Hemodialysis Sessions  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)