(Medicare Claims Processing Manual)

99201-99205 Office or Other Outpatient Visit for a New Patient 99211-99215 Office or Other Outpatient Visit for an Established Patient 99221-99223 Initial Ho spital Care for a New or Established Patient  99238-99239 Hospital Discharge Day Management Services  99241-99245 Office or Other Outpatient Consultations, New or Established Patient  99251-99255 Initial Inpatient Consultations, New or Established Patient 99291-99292 Critical Care Services   In the absence of one of these codes being reported with the 25 modifier and meeting the other requirements listed above, pay only the dialysis service and deny the evaluation and management service. Furthermore, payment is not allowed for more than one dialysis service per day.   180 - Noninvasive Studies for ESRD Patients - Facility and Physician Services  (Rev. 3650, Issued: 11- 10-16, Effective: 02-10-17, Implementation: 02-10-17)  For Medicare coverage of noninvasive vascular studies, see the Medicare Benefit Policy Manual, Chapter 11.  For dialysis to take place there must be a means of access so that the exchange of waste products may occur.  As part of the dialysis treatment, ESRD facilities are responsible for monitoring access, and when occlusions occur, either declot the access or refer the patient for appropriate treatment.  Procedures associated with monitoring access involve taking venous pressure, aspirating thrombus, observing elevated recirculation time, re duced urea reduction ratios, or collapsed shunt, etc.  All such procedures are covered under the composite rate.   ESRD facilities may not monitor access through noninvasive vascular studies such as duplex and Doppler flow scans and bill separately for these procedures.  Noninvasive vascular studies are not covered as a separately billable service if used to monitor a patients vascular access site.   Medicare pays for the technical component of the procedure in the composite payment rate.  Where there are si gns and symptoms of vascular access problems, Doppler flow studies may be used as a means to obtain diagnostic information to permit medical intervention to address the problem.  Doppler flow studies may be considered medically necessary in the presence of  signs or symptoms of possible failure of the ESRD patients vascular access site, and when the results are used in determining the clinical course of the treatment for the patient.   The only Current Procedural Terminology (CPT) billing code for noninvasive vascular testing of a hemodialysis access site is 93990.  A/B MACs (B) must deny separate billing of the technical component of this code if it is performed on any patient for whom the ESRD composite rate for dialysis is being paid, unless ther e is appropriate medical indication of the need for a Doppler flow study.   When a dialysis patient exhibits signs and symptoms of compromise to the vascular access site, Doppler flow studies may provide diagnostic information that will determine the appropriate medical intervention.  Medicare considers a Doppler flow study medically necessary when the beneficiarys dialysis access site manifests signs or symptoms associated with vascular compromise, and when the results of this test are necessary to determi ne the clinical course of treatment.   Examples supporting the medical necessity for Doppler flow studies include:   a. Elevated dynamic venous pressure >200mm HG when measured during dialysis with the blood pump set on a 200cc/min.,   b. Access recirculation  of 12 percent or greater,   c. An otherwise unexplained urea reduction ration <60 oercebtm abd   d. An access with a palpable water hammer pulse on examination, (which implies venous outflow obstruction).  Unless the documentation is provided supporting t he necessity of more than one study, Medicare will limit payment to either a Doppler flow study or an arteriogram (fistulogram, venogram), but not both.   An example of when both studies may be clinically necessary is when a Doppler flow study demonstrates reduced flow (blood flow rate less than 800cc/min or a decreased flow of 25 percent or greater from previous study) and the physician requires an arteriogram to further define the extent of the problem.  The patients medical record(s) must provide documentation supporting the need for more than one imaging study.   This policy is applicable to claims from ESRD facilities and all other sources, such as independent diagnostic testing facilities, and hospital outpatient departments.  A/B MACs (B) shall develop  LMRP for Doppler flow studies if this service meets the criteria listed in the Medicare Program Integrity Manual, Chapter 1.  This provides guidance to contractors on the scope, purpose, and meaning of LMRP.  The professional component of the procedure is  included in the monthly capitation payment (MCP) (See 140 above.) The professional component should be denied for code 93990 if billed by the MCP physician.  Medically necessary services that are included or bundled into the MCP (e.g., test interpretations) are separately payable when furnished by physicians other than the MCP physician.  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Four.   Group Code: CO  CARC: 24  RARC: N/A  MSN:16.32  Billing for monitoring of hemodialysis access using CPT codes for noninvasive vascular studies other than 93990 is considered a misrepre sentation of the service actually provided and contractors will consider this action for fraud investigation.  They will conduct data analysis on a periodic basis for noninvasive diagnostic studies of the extremities (including CPT codes 93922, 93923, 93924, 93925, 93926, 93930, 93931, 93965, 93970, 93971).  Contractors should handle aberrant findings under normal program safeguard processes by taking whatever corrective action is deemed necessary.   190 - Appeal Rights for Denied Claims   For appeal rights i f the claim is denied see Chapter 29.   200  Utilization of REMIS for A/B MAC (B) Claims Adjudication  (Rev. 82, 02- 06-04)  Renal Management Information System (REMIS) determines the Medicare coverage periods for ESRD patients and serves as the primary mechanism to store and access information in the ESRD Program Management and Medical Information System Database.  REMIS is used by CMS and the renal community to monitor the Medicare status, transplant activities, dialysis activities, and Medicare utiliza tion of ESRD patients and their Medicare provider.   The following fields are contained in the (Dialysis) auxiliary file:    ESRD Coverage Start Date  (The date on which the beneficiary is entitled to Medicare, in some part, because of a diagnosis of End Stage  Renal Disease.)    ESRD Coverage Source Code (The source of the information that establishes Medicare- based End- Stage Renal Disease Coverage; A= Part A and Dialysis Training, B= Part A and Dialyzing (No 3 month wait), C= Part A and 3 months after Dialysis, D= Part A and Functioning Transplant, E= Part A and Month of Pre-Transplant Stay, F= Part A and ESRD (Verified Source), Blank= No ESRD Involvement.)    ESRD Coverage Termination Date  (The date on which the beneficiary is no longer entitled to Medicare under ESRD Provisions.)    ESRD Coverage Termination Reason (A code that indicates the reason Medicare- based End- Stage Renal Disease Coverage was terminated; codes: A= Month of transplant plus 36 months, B=Last month of chronic dialysis, C= Part A termination, D=D eath, E=ESRD ended: other verified source.)    ESRD Dialysis Start Date  (A date that indicates when ESRD dialysis started.)    ESRD Dialysis Stop Date  (A date that indicates when ESRD dialysis ended.)    ESRD Transplant Start Date (A date that indicates when a k idney transplant operation occurred.)    ESRD Transplant Stop Date (A date that indicates when a kidney transplant failed.)    The above data elements are in CWF and stored in the dialysis auxiliary file, which can be used to identify a beneficiarys ESRD eli gibility.  This data source will assist carriers in reviewing overpayment determination and accurately processing claims.  Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR #  R10640CP  08/06/2021 Update of Internet Only Manual (IOM), Pub. 100-04, Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims  09/07/2021 12079 R10236CP 07/31/2020 Update to the IOM Publication (Pub) 100-04, Medicare Claims Processing Manual, Chapters 1, 6, 8, 17, 20, 22, 24, and 31 Referencing the Active Universal Resource Locators (UR Ls) for the Washington Publishing Company (WPC) and the ASC X12 Organizations, and Updates to the HIPAA Eligibility Transaction System (HETS)  08/31/2020 11857 R4202CP 01/18/2019 Update to Pub. 100-04 Chapters 8, 20, and 24 to Provide Language-Only Changes for the New Medicare Card Project  02/19/2019 10964 R4105CP 08/03/2018 System Changes to Implement Epoetin Alfa Biosimilar, Retacrit for End Stage Renal Disease (ESRD) and Acute Kidney Injury (AKI) Claims  01/07/2019 10839 R4010CP 03/23/2018 Revisions to Medicare Claims Processi ng Manual for End Stage Renal Disease  06/26/2018        10541  R3650CP  11/10/2016 Updates to Pub. 100-04, Chapters 8, 13 and 14 to Correct Remittance  Advice Messages  02/10/2016 9841 R3311CP 08/06/2015 End Stage Renal Disease (ESRD) Home Dialysis Policy  09/08/2015 9265 R3139CP 12/02/2014 Implementation of Changes in the End-Stage Renal Disease Prospective Payment System (ESRD PPS) for Calendar Year (CY) 2015 01/05/2015 8978 R3125CP 11/14/2014 Implementation of Changes in the End-Stage Renal Disease Prospective Payment System (ESRD PPS) for Calendar Year 01/05/2015 8978 Rev #  Issue Date  Subject  Impl Date  CR #  (CY) 2015   Rescinded and replaced by Transmittal 3139  R3116CP  11/06/2014 Elimination of the 50/50 Payment Rule for Laboratory Services on End Stage Renal Disease (ESRD) Claims  04/06/2015 8957 R3053CP 08/28/2014 Update to Pub. 100- 04, Chapters 7 and 8 to Provide Language -Only Changes for Updating ICD-10 and ASC X12 09/30/2014 8579 R2905CP  03/14/2014 Update to Pub. 100- 04, Chapters 7 and 8 to Provide Language -Only Changes for Updating ICD -10 and ASC X12   Rescinded and replaced by Transmittal 3053 10/01/2014 8579 R2839CP  12/13/2013 Implementation of Changes in the End -Stage Renal Disease Prospective Payment System (ESRD PPS) for Calendar Year (CY) 2014  01/06/2014 8472 R2831CP 11/29/2013 Implementation of Changes in the End -Stage Renal Disease Prospective Payment System (ESRD PPS) for Calendar Year (CY) 2014  Rescinded and replaced by Transmittal 2839  01/06/2014 8472 R2688CP 04/26/2013 Repo rting End Stage Renal Disease (ESRD) Drugs Administered Through the Dialysate  07/01/2013 8256 R2545CP  01/31/2013 Changes Applicable to the Billing of D rugs on ESRD Claims  07/012013 8174 R2582CP  11/02/2012 New Erythropoietin Stimulating Agent (ESA) Peginesatide  Requirements for End Stage Renal Disease (ESRD)  04/01/2013 8050 R2577CP 11/01/2012 Update to the Fiscal Intermediary Shared Systems (FISS) for the End  Stage Renal Disease (ESRD) Quality Incentive Program (QIP) Adjustments for Childrens Hospitals  04/01/2013 8066 R2588CP