(Medicare Benefit Policy Manual)

There are renal dialysis equipment and supplies that are not used in other provider settings.  These equipment and supplies are also listed in the document titled Items and Services Subject to Consoli dated Billing for the ESRD PPS.  These supplies and equipment are not otherwise covered by Medicare ; therefore DME suppliers are not able to bill any of the supplies on this list using the AY modifier .  30 - Home Dialysis (Rev. 171, Issued: 06 -07-13, Effe ctive: 01 -01-11, Implementation: 09- 09-13)  For home dialysis services furnished prior to January 1, 2011, a beneficiary selected one of two methods to secure home dialysis items and services.  Method I was when the ESRD facility with which the patient is associated assumes total responsibility for furnishing all home dialysis items or services.  The second was Method II, which was when the beneficiary dealt directly with a single dialysis supplier to secure home dialysis items and services.  Beginning January 1, 2011, Method II is no longer an option for home dialysis under Medicare.  Therefore, all home dialysis patients are under Method I.  For more information on Method II, see 10.E of this chapter.  30.1 - Home Dialysis Items and Services  (Rev. 200, Is sued: 12 -02-14, Effective: 01- 01-15, Implementation: 01- 05-15)  Effective January 1, 2011, payment for renal dialysis services furnished for home dialysis are covered under the ESRD PPS and are not separately paid.  ESRD facilities shall not bill Medicare beneficiaries directly when they furnish renal dialysis items an d services included under the ESRD PPS.  T he ESRD facility receives the same Medicare dialysis payment rate for home patients as it would receive for an in -facility patient under the ESRD PPS.   The ESRD facility is responsible for the overall management of  the home dialysis patient, including assuring that the patient is provided with equipment and supplies that are functional.  This means the ESRD facility is responsible for delivering, installing, monitoring and maintaining supplies and equipment necessar y to furnish all modalities of home dialysis.   All renal dialysis items and services described in this section were included under the composite rate and are included under the ESRD PPS.  Therefore these items and services must be furnished by the ESRD fac ility, either directly or under arrangement.  The ESRD facility is responsible for all renal dialysis items and services which include but is not limited to:    Medically necessary home dialysis equipment (see 20.4.A of this chapter);    Home dialysis support  services (see below), which include but is not limited to the delivery, installation, maintenance, repair and testing of home dialysis equipment and support equipment;    Procurement and delivery of all necessary home dialysis supplies;    Renal dialysis laboratory tests;   Renal dialysis drugs and biologicals; and    All dialysis services furnished by the ESRD facilitys staff.   Some examples (but not an all -inclusive list) of renal dialysis items and services included in the ESRD PPS and may not  be billed s eparately when furnished by an ESRD facility are:    Staff time used to administer blood;  Declotting of shunts and any supplies used to declot shunts;   Oxygen and the administration of oxygen; and   Staff time used to administer separately billable items.   For additional information regarding conditions for coverage for home dialysis services, refer to 42 CFR 494.  A.  Home Dialysis Hemodialysis and Peritoneal Support Services   Home dialysis support services identified at 42 CFR 494.100 may be furnished in the home or in the ESRD facility.  Support services may be provided directly or via an agreement or arrangement with another approved ESRD facility.  Support services include (but are not limited to):   1. Periodic monitoring of a patients adaptation to home dial ysis and performance of dialysis, including provisions for visits to the home or the ESRD facility;   2. Emergency visits by qualified ESRD facility personnel;  3. Services provided by a qualified social worker and a qualified dietitian, made in accordance with a plan prepared and periodically reviewed by a professional team which includes the physician;   4. Individuals unscheduled visits to an ESRD facility made on an as -needed basis; e.g., assistance with difficult access situations;   5. Renal dialysis laboratory tes ts covered under the ESRD PPS;   6. Providing, installing, repairing, testing, and maintaining home dialysis equipment, including appropriate water testing and treatment;   7. Ordering of supplies on an ongoing basis;   8. Maintaining and submitting all required docum entation to the ESRD network;   9. A record keeping system that ensures continuity of care;   10. Changing necessary tubing;   11. Watching the patient perform dialysis to assure that it is done correctly and to review any aspects of the technique that may require modif ication; and   12. Inspecting the access site and document any access site infections that may require a physician intervention or hospitalization.  The full range of home dialysis support services required by home patients are included in the ESRD PPS.  ESRD support services must be furnished periodically.  These services will usually be furnished during a periodic follow -up visit, but they may be furnished at separate times.  They may be furnished in the ESRD facility or in the home.   NOTE:  For additional inf ormation on  renal dialysis services furnished on or after  January 1, 2011, and paid under the ESRD PPS, refer to 20 of this chapter.  B.  In -facility Dialysis Sessions Furnished to Home Patients Who Are Traveling  Patients who are normally home dialysis  patients may be dialyzed by a Medicare certified ESRD facility on an in -facility basis when traveling away from home.  Patients who normally dialyze in an ESRD facility may wish to dialyze temporarily in another facility or as home dialysis patients while  they travel or vacation.  See Medicare Claims Processing Manual, Chapter 8, Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, 100, for billing services when traveling.   C.  Staff Assisted Home Dialysis   Effective January 1,  2011, renal dialysis services for patients receiving home dialysis may only be billed under Method I.  Staff -assisted home dialysis using nurses to assist ESRD beneficiaries is not included in the ESRD PPS and is not a Medicare covered service.   If an ent ity wishes to bill Medicare for a non- covered renal dialysis service they provide to Medicare beneficiaries, they must first enroll with the appropriate Medicare contractor (assuming that Medicare recognizes such type of provider/supplier for billing purposes).  Providers/suppliers must enroll in the jurisdiction(s) where they intend to provide services and follow the jurisdiction rules specified in Pub. 100-04, chapter 1, 10.   Once the ESRD facility is enrolled with the appropriate Medicare contractor(s),  they should work with the contractor(s) to determine the appropriate code to bill for the service, if any.  Finally, entities enrolled in Medicare as Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) suppliers may not bill the DME MAC s for professional or quasi -professional services, including but not limited to nurse caregiver staff -assistance services.  Instead, if a DMEPOS supplier is permitted under State law to furnish such services under its licensure and wishes to bill Medicare for such services, it must enroll with the appropriate Medicare contractor under such professional or quasi -professional service category as Medicare may recognize for Medicare billing purposes, if any.   For additional information, contact your appropriate  Medicare contractor.   30.2 - Home Dialysis Training  (Rev. 200, Issued: 12- 02-14, Effective: 01- 01-15, Implementation: 01- 05-15)  Self-dialysis and home dialysis training are programs provided by Medicare certified ESRD facilities that educate ESRD patient s and their caregivers to perform self -dialysis in the ESRD facility or home dialysis (including CAPD and CCPD) with little or no professional assistance.  Self -dialysis training can occur in the patients home or the in- facility when it is provided by the  qualified staff of the ESRD facility.  CMS expects that the patients who elect for home dialysis are good candidates for home dialysis training, and therefore, will successfully complete their method of training before reaching the maximum number of sessi ons allotted.  Dialysis training services are reimbursed in accordance with Pub. 100- 04, Medicare Claims Processing Manual, chapter 8, 50.8.   Home dialysis training services and supplies may include but are not limited to personnel services; dialysis supplies, parenteral items used in dialysis, written training manuals and materials, and renal dialysis laboratory tests.  For more information on the requirements for ESRD facilities, see 42 CFR Part 494.  An ESRD facility may bill a maximum of 25 trainin g sessions per patient for hemodialysis training and 15 sessions for CCPD and CAPD.  For information on how home dialysis training treatments are paid, see 60.C of this chapter.   NOTE:   ESRD facilities that are certified for home dialysis training and sup port services are expected to provide training throughout the home dialysis experience.  Information regarding home dialysis training certification may be found at the following link: http://www.cms.gov/Medicare/Provider -Enrollment -and-Certification/GuidanceforLawsAndRegulations/Dialysis.html .  A.  Hemodialysis Training  The average training time for hemodialysis patients is based upon 5- hour sessions given 3 times per week.  In some dialysis programs, the dialysis partner is trained to perform the dialysis treatment in its entirety.  The patient plays a secondary role.  In other programs, the patient performs most of the treatment an d is only aided by a helper.   B.  Intermittent Peritoneal Dialysis Training (IPD)   The IPD patients can be trained in approximately 4 weeks.  IPD is usually accomplished in sessions of 10- 12 hours.  It is sometimes accomplished in fewer sessions of longer duration.  In the IPD program, the patients partner is usually trained to carry out the dialytic care.  The patient plays a secondary or minimal role, as most are unable to perform self -care dialysis.  IPD patients are usually unable to perform self -care dialysis because of other debilitating conditions.  C.  Continuous Ambulatory Peritoneal Dialysis (CAPD) Training  The CAPD training is furnished in sessions that can last up to 8 hours (one session per day) 5 - 6 days per week.  Typically, 6 - 8 CAPD exch anges can be performed per day for the purpose of teaching the patient the CAPD technique; however, no specific number of exchanges is required.  Normally patients are trained within 2 weeks (5 -  6 training sessions per week); however, up to 15 sessions (i .e., 15 training days) may be covered routinely.  Additional CAPD training sessions are covered only when documented for medical necessity.  Extra training sessions raise questions about either the adequacy of CAPD for the patient or the patients capacity  to learn or perform the CAPD technique.  The patients physician should address these questions in the explanation of the need for extra training sessions.  The A/B MAC (A) will make a determination whether or not to permit training sessions in excess of 15.  Once the patient is trained, CAPD is primarily a home service because the patient performs CAPD 24 hours a day.  Therefore, renal dialysis services that are specifically CAPD services are training services and include associated services that are furn ished in the ESRD facility during training.  Persons who are primarily treated by CAPD may also require in -facility dialysis, either intermittent peritoneal or hemodialysis, occasionally.   Prior to the implementation of the ESRD PPS, there were specific fr equency coverage requirements of the routine laboratory services furnished for CAPD.  The CAPD laboratory tests that were included under the composite rate are those monthly tests listed in (20.2.E.1.b of this chapter) and they are covered during training .  The coverage frequency screens for these laboratory tests did not apply during training, as these tests were commonly given during each training session.  All of these tests were included in the training screen, regardless of how frequently they were gi ven, and may have been billed separately.  Under the composite rate, separately billable laboratory tests must have been documented for medical necessity.  However, under the ESRD PPS all renal dialysis laboratory services are included in the bundle regardless of the frequency they are furnished.