(Medicare Claims Processing Manual)

If a home dial ysis patient receives dialysis in a dialysis center or other outpatient facility during the month, the MCP physician or practitioner is paid the management fee for the home dialysis patient and cannot bill the ESRD -related services codes for managing center based patients.   This situation should be coded using the ESRD related services codes for a home dialysis patient per full month. Physicians and practitioners should use the ESRD related services codes for a home dialysis patient per full month when bill ing for outpatient ESRD -related services when a home dialysis patient receives dialysis in a dialysis center or other outpatient facility during the month.   Physicians and practitioners should use the ESRD related services codes for a home dialysis patient per full month for patients that switch modalities regardless of whether the ESRD beneficiary went from home dialysis to center -based dialysis, or vice versa, and regardless of the proportion of the month that the beneficiary was receiving each modality.   140.2 - Payment for ESRD -related services (Per Diem)  (Rev. 1456, Issued: 02- 22-08, Effective: 03- 24-08, Implementation: 03- 24-08)  Physicians and practitioners may receive payment for managing patients on dialysis for less than a full month of care in spe cific circumstances as discussed in this section.  Payment for ESRD related services, less than a full month, is paid on a per diem basis.  Per diem ESRD -related services should be coded using the ESRD related services (less than full month), per day HCPCS  codes for ESRD -related services furnished in the situations described below.   Home dialysis patients (less than full month);   Transient patients  Patients traveling away from home (less than full month);   Partial month where there was  one or more face- to-face visits without a complete assessment of the patient and the patient was either hospitalized before a complete assessment was furnished, dialysis stopped due to death, or the patient had a transplant.   Patients who have a permanent  change in their MCP physician during the month.  The ESRD -related services (less than full month), per day HCPCS codes should only be used for the circumstances described above.  The per diem codes may not  be used for a full month when a complete monthly assessment is not furnished.  140.2.1 - Guidelines for Physician or Practitioner Billing -- (Per Diem)  (Rev. 3311, Issued: 08- 06-15, Effective: 01- 01-15, Implementation: 09- 08-15)  A.  Home dialysis, transient patient and partial month   When submitting cla ims for ESRD -related services (less than full month) per day, the physician or practitioner should specify the number of days he or she was responsible for the beneficiarys outpatient ESRD -related services during the month.   Only one code should be used t o report the daily management of home dialysis patients, transient patients, and for partial month scenarios.  For example, if a home dialysis patient receives dialysis at home for two weeks and is hospitalized for the remainder of the month, then 14 units  of the age appropriate ESRD -related per day code is billed.  The MCP service is not billed.   For transient patients, the physician or practitioner responsible for the transient patients ESRD -related care should bill the appropriate ESRD -related services,  per day code.  Only the physician or practitioner responsible for the traveling ESRD patients care is permitted to bill for ESRD -related services using the per diem ESRD -related services HCPCS codes.   For home dialysis patients (less than full month) if the MCP physician or practitioner furnishes a complete monthly assessment of the ESRD beneficiary and at least one face -to-face patient visit during the month, he or she should bill for the age appropriate home dialysis MCP service.  For example, if a home dialysis patient was hospitalized during the month and at least one face- to-face outpatient visit and complete monthly assessment was furnished, the MCP physician or practitioner should bill for the full home dialysis MCP service.   For partial month scenarios resulting from hospitalization, kidney transplant, or the patient expired, if the MCP physician or practitioner furnished a complete monthly assessment of the patient, he or she should bill using the age appropriate MCP service that reflects the number of visits furnished during the month.  Example #1: An ESRD beneficiary was hospitalized on the tenth through the twentieth day of the month.  On the third day of the month, the MCP physician or practitioner furnished a face -to-face visit including a  complete assessment and a subsequent outpatient visit on the twenty -fifth day of the month.  While the patient was hospitalized, an inpatient ESRD -related visit was furnished.   In this scenario, the MCP physician or practitioner may bill for the appropria te outpatient MCP service based on the age of the beneficiary and number of visits furnished during the month.  The physician or practitioner who furnished the inpatient visit may bill for the appropriate inpatient ESRD -related service code.   Example #2: A n ESRD beneficiary vacationing in Florida is away from his or her home dialysis site from August fifteenth through September seventh.  On August tenth, the MCP physician furnishes a face- to-face visit.  For the month of September, the MCP physician furnishes a visit on the ninth and a subsequent visit on the twenty -fifth of the month.  A physician in Florida is responsible for the beneficiarys ESRD -related care from August fifteenth through September seventh.   In this scenario, the physician or practitione r responsible for the transient patients ESRD -related care bills sixteen units of the age appropriate ESRD -related services for dialysis less than full month, per day code for the month of August and seven units of the per day code for the month of Septem ber.  The MCP physician bills the MCP service with one visit for the month of August and the MCP service with two to three visits for the month of September.   If the transient beneficiary is under the care of a physician or practitioner other than his or her regular MCP physician for an entire calendar month, the physician or practitioner responsible for the transient patients ESRD -related care must furnish a complete assessment and bill for ESRD -related services under the MCP.   B.  Patient has a permanent  change in their MCP physician during the month  ESRD -related services (less than full month) per day HCPCS codes should be billed in situations where an ESRD beneficiary permanently changes their MCP physician during the month.  For example, the new MCP physician has the ongoing responsibility for the evaluation and management of the patients ESRD -related care and is not part of the same group practice or an employee of the first MCP physician.  The new MCP physician should use the appropriate per diem HC PCS code when submitting claims for ESRD -related services for the remainder of the month, when the first MCP physician furnishes a complete assessment of the beneficiary during the month.  If the first MCP physician does not furnish a complete assessment of the patient during the month the patient permanently changes their MCP physician, the new MCP physician may bill for the appropriate MCP service based on the age of the patient and number of visits furnished and the first MCP physician may bill the appropriate per day HCPCS code as discussed above.   Example: An ESRD patient residing in Virginia Beach, Virginia for the first 20 days of the month, moves to Atlanta, Georgia.  As a result, a different physician or practitioner is now responsible for the ongoi ng management of the beneficiarys ESRD -related care.  Both the first and second MCP physician furnishes a visit with a complete assessment of the patient and establishes a monthly plan of care.  In this situation, the first MCP physician should bill the M CP service that reflects the number of visits he or she furnished during the month and the second MCP physician should bill the age appropriate per day ESRD -related services code.  Thereafter, the new MCP physician would bill for the MCP service.   In this example, if the first MCP physician does not provide a complete assessment of the patient, he or she should bill 20 units of the per day ESRD -related services code, but may not bill for the MCP during the month the beneficiary permanently changes his or he r MCP physician.  The second MCP physician may bill for the MCP service after furnishing a complete monthly assessment of the ESRD beneficiary that includes establishing the patients plan of care and at least one face- to-face visit.   140.3 - Data Elements Required on Claim for Monthly Capitation Payment  (Rev. 10236, Issued: 07 -31-2020, Effective: 08- 31-2020, Implementation: 08- 31-2020)    On Form CMS -1500   A. Elements 1 through 13 of the Form CMS -1500 are completed in accordance with the regular instructions   B. Elements 14 through 20 of the Form CMS -1500 are omitted.   C. Element 32 must contain the name and address of the facility involved with the patients maintenance care or training, and 32a must contain the facility NPI.   D. Element 21 must show the diagnosis.  Indicate in Element 19 whether the patient is in training for self -dialysis.   E. Element 24A must show the dates of service during the month that are included in the MCP.  The period includes the full calendar month the MCP physi cian or practitioner was responsible for the beneficiary's ESRD related care.   For the first month the beneficiary begins dialysis treatments, the first date the dialysis treatments begin through the end of the calendar month should be used as the dates of  service.   For outpatient ESRD -related services furnished for less than a full month, per day as discussed in 140.2 (e.g. transient patients, partial month due to hospitalization, transplant, or death), the first and last date the physician or practitioner  was responsible for the beneficiarys ESRD -related care during the month should be used as the dates of service.  Non-continuous dates should be billed on separate claim lines, (e.g. 1/1/08  1/7/08 and 1/20/08  1/31/08).  A separate monthly claim should be submitted when the duration of ESRD -related services, per day, overlaps two different months as discussed in 140.21 (e.g. August 15 -   September 7).   F. The remainder of the Form CMS -1500 is completed in accordance with the general instructions.  On AS C X12 Professional Format   Instructions for completing the ASC X12 837 professional claim format are in the related implementation guide, available on the official Washington Publishing Company website.   140.4 - Controlling Claims Paid Under the Monthly Capitation Payment Method  (Rev. 1456, Issued: 02- 22-08, Effective: 03- 24-08, Implementation: 03- 24-08)  Contractors must be able to identify dialysis patient history records and physicians who furnish services related to dialysis.   In processing claims reimbursed under this method, contractors must assure that:    Only one monthly payment is made for any renal disease patient per month;    The MCP payment is made after the month has passed; i.e., do not pay the MCP in advance of the services actually furnish ed;   The payment amount is based on the age of the beneficiary and the number of visits furnished during a calendar month (center based patients);    Duplicate charges billed as a duplicate MCP or as separate charges for services covered by the monthly payme nt are denied;    Where several physicians or practitioners form a team to provide the monthly continuity of services to a group of patients, make only one monthly payment for each patient.    Concurrent services by another physician or practitioner who is par t of the MCP practice team are covered and reimbursed separately only for services not included in the MCP (e.g. a visit not related to managing the patients ESRD); and    If payment for inpatient hospital services is claimed in addition to the MCP, and assignment is taken only with respect to the MCP, follow the instructions in Pub. 100-04, chapter 1, 30.3.12.3.  Contractors must conduct periodic review of a randomly selected sample of patients histories with reimbursement under the MCP method, to evaluate whether the number of and types of services billed separately from the MCP are appropriate considering the individual patients medical condition.  Make separate payments for medically necessary services that are included or bundled into the MCP (e.g., test interpretations) when furnished by physicians other than the monthly capitation payment physician. According to the Renal Physicians Association, these test interpretations are billed separately only in rare circumstances.   150 - Physicians Self -Dialysis Training Services  (Rev. 1, 10- 01-03)