(Medicare Claims Processing Manual)

 Performance of periodic physical assessments, based upon the patients clinical stability, in order to determine the necessity for alterations in various  aspects of the patients prescription. Similarly, the physician reviews the results of periodic laboratory testing in order to determine the need for alterations in the patients prescription, such as changes in the amount and timing of phosphate binders or dose of erythropoietin.   Periodic assessment of the adequacy and function of the patients dialysis access appropriate tests and antibiotic therapy.    Interpretations of the following tests:   o Bone mineral density studies (CPT codes 76070, 76075, 78350, a nd 78351);   o Noninvasive vascular diagnostic studies of hemodialysis access (CPT codes 93925, 93926, 93930, 93931, and 93990);   o Nerve conduction studies (CPT codes 95900, 95903, 95904, 95925, 95926, 95927, 95934, 95935, and 95936);   o Electromyography studies  (CPT codes 95860, 95861, 95863, 95864, 95867, 95867, 95869, and 95872).   Periodic review and update of the patients short -term and long -term care plans with staff.    Coordination and direction of the care of patients by other professional staff, such as dieticians and social workers.    Certification of the need for items and services such as durable medical equipment and home health care services. Care plan oversight services described by CPT code 99375 are included in the MCP and may not be separately reported.  B.  Services Excluded from Monthly Capitation Payment   The following physician services furnished to the physicians ESRD patients are excluded from the MCP and should be paid in accordance with the physician fee schedule:   1.  Administration of he patitis B vaccine.   2.  Surgical services such as:    Temporary or permanent hemodialysis catheter placement;   Temporary or permanent peritoneal dialysis catheter placement;   Repair of existing dialysis accesses;   Placement of catheter(s) for thrombolytic therapy;   Thrombolytic therapy (systemic, regional, or access catheter only; hemodialysis or peritoneal dialysis);   Thrombectomy of clotted cannula;   Arthrocentesis;   Bone marrow aspiration; and  Bone marrow biopsy.   3.  Interpretation of tests that have a prof essional component such as:    Electrocardiograms (12 lead, Holter monitor, stress tests, etc.);   Echocardiograms;   24-hour blood pressure monitor;   Biopsies; and   Spirometry and complete pulmonary function tests.  4.  Complete evaluation for renal transplantati on. While the physician assessment of whether the patient meets preliminary criteria as a renal transplant candidate is included under the MCP, the complete evaluation for renal transplantation is excluded from the MCP   5.  Evaluation of potential living t ransplant donors.  6.  The training of patients to perform home hemodialysis, self hemodialysis, and the various forms of self peritoneal dialysis.   7.  Non- renal related physicians services. These services may be furnished by the physician providing renal care or by another physician. They may not be incidental to services furnished during a dialysis session or office visit necessitated by the renal condition. The physician must provide documentation that the illness is not related to the renal condit ion and that the added visits are required.  The contractors medical staff determines whether additional reimbursement is warranted for treatment of the unrelated illness. For example, the medical management of diabetes mellitus that is not related to the dialysis or furnished during a dialysis session is excluded.  8.  Covered physician services furnished to hospital inpatients.  9.  All physician services that antedate the initiation of outpatient dialysis.   10.  Covered physician services furnished by a nother physician when the patient is not available to receive the outpatient services as usual; for example, when the patient is traveling out of town.   140.1 - Payment for ESRD -Related Services Under the Monthly Capitation Payment (Center Based Patients)  (Rev. 2269, Issued: 08- 05-11, Effective: 01- 01-11, Implementation: 11- 07-11)  Physicians and practitioners managing center based patients on dialysis are paid a monthly rate for most outpatient dialysis -related physician services furnished to a Medicare ES RD beneficiary.  The payment amount varies based on the number of visits provided within each month and the age of the ESRD beneficiary.  Under this methodology, separate codes are billed for providing one visit per month, two to three visits per month and four or more visits per month.  The lowest payment amount applies when a physician provides one visit per month; a higher payment is provided for two to three visits per month.  To receive the highest payment amount, a physician or practitioner would have  to provide at least four ESRD -related visits per month.  The MCP is reported once per month for services performed in an outpatient setting that are related to the patients ESRD.   The physician or practitioner who provides the complete assessment, establ ishes the patients plan of care, and provides the ongoing management is the physician or practitioner who submits the bill for the monthly service.   a.  Month defined.   For purposes of billing for physician and practitioner ESRD related services, the term  month means a calendar month.  The first month the beneficiary begins dialysis treatments is the date the dialysis treatments begin through the end of the calendar month.  Thereafter, the term month refers to a calendar month.   b.  Determination of the age of beneficiary.   The beneficiarys age at the end of the month is the age of the patient for determining the appropriate age related ESRD -related services code.   c.  Qualifying Visits Under the MCP    General policy.   Visits must be furnished face -to-face by a physician, clinical nurse specialist, nurse practitioner, or physicians assistant.    Visits furnished by another physician or practitioner (who is not the MCP physician or practitioner).   The MCP physician or practitioner may use other physicians or qualified nonphysician practitioners to provide some of the visits during the month.  The MCP physician or practitioner does not have to be present when these other physicians or practitioners provide visits.  In this instance, the rules are consistent with the requirements for hospital split/shared evaluation and management visits.  The non- MCP physician or practitioner must be a partner, an employee of the same group practice, or an employee of the MCP physician or practitioner.  For example, the phy sician or practitioner furnishing visits under the MCP may be either a W -2 employee or 1099 independent contractor.  When another physician is used to furnish some of the visits during the month, the physician who provides the complete assessment, establis hes the patients plan of care, and provides the ongoing management should bill for the MCP service.   If the nonphysician practitioner is the practitioner who performs the complete assessment and establishes the plan of care, then the MCP service should be  billed under the PIN of the clinical nurse specialist, nurse practitioner, or physician assistant.    Residents, interns and fellows.  Patient visits by residents, interns and fellows enrolled in an approved Medicare graduate medical education (GME) program  may be counted towards the MCP visits if the teaching MCP physician is present during the visit.    Patients designated/admitted as hospital observation status.  ESRD -related visits furnished to patients in hospital observation status that occur on or after January 1, 2005, should be counted for purposes of billing the MCP codes.   Visits furnished to patients in hospital observation status are included when submitting MCP claims for ESRD -related services.    ESRD -related visits furnished to beneficiaries resi ding in a SNF.   ESRD -related visits furnished to beneficiaries residing in a SNF should be counted for purposes of billing the MCP codes.    SNF residents admitted as an inpatient.   Inpatient visits are not counted for purposes of the MCP service.  If the b eneficiary residing in a SNF is admitted to the hospital as an inpatient, the appropriate inpatient visit code should be billed.   140.1.1 - Payment for Managing Patients on Home Dialysis (Rev.  2269, Issued: 08- 05-11, Effective: 01- 01-11, Implementation: 11- 07-11)  Physicians and practitioners managing ESRD patients who dialyze at home are paid a single monthly rate based on the age of the beneficiary.  The MCP physician (or practitioner) must f urnish at least one face -to-face patient visit per month for the home dialysis MCP service.  Documentation by the MCP physician (or practitioner) should support at least one face -to-face encounter per month with the home dialysis patient. Medicare contract ors may waive the requirement for a monthly face -to-face visit for the home dialysis MCP service on a case by case basis, for example, when the nephrologists notes indicate that the physician actively and adequately managed the care of the home dialysis p atient throughout the month.  The management of home dialysis patients who remain a home dialysis patient the entire month should be coded using the ESRD -related services for home dialysis patients HCPCS codes.   a. Month defined.   For purposes of billing f or physician and practitioner ESRD related services, the term month means a calendar month.  The first month the beneficiary begins dialysis treatments is the date the dialysis treatments begin through the end of the calendar month.  Thereafter, the term  month refers to a calendar month.  b. Qualifying Visits under the MCP    General policy.   Visits must be furnished face -to-face by a physician, clinical nurse specialist, nurse practitioner, or physicians assistant.    Visits furnished by another physician or practitioner (who is not the MCP physician or practitioner).   The MCP physician or practitioner may use other physicians or qualified nonphysician practitioners to provide the visit(s) during the month.  The MCP physician or practitioner does not have to be present when these other physicians or practitioners provide visit(s).  The non- MCP physician or practitioner must be a partner, an employee of the same group practice, or an employee of the MCP physician or practitioner.  For example, the physician or practitioner furnishing visits under the MCP may be either a W -2 employee or 1099 independent contractor.   When another physician is used to furnish some of the visits during the month, the physician who provides the complete assessment, establishes the  patients plan of care, and provides the ongoing management should bill for the MCP service.   If the nonphysician practitioner is the practitioner who performs the complete assessment and establishes the plan of care, then the MCP service should be billed under the PIN of the clinical nurse specialist, nurse practitioner, or physician assistant.    Residents, interns and fellows. Patient visits by residents, interns and fellows enrolled in an approved Medicare graduate medical education (GME) program may be counted towards the MCP visits if the teaching MCP physician is present during the visit.   140.1.2 - Patients Who Switch Modalities (Center to Home and Vice Versa)  (Rev. 1999, Issued: 07- 09-10, Effective: 01- 01-11, Implementation: 01- 03-11)  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)