(Medicare Claims Processing Manual)

 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)  Pay physicians for physician training services furnished to dialysis patients undergoing training by a flat fee of $500 (subject to the deductible and coinsurance requirements) for each patient under the physicians supervision during the training course. Pay this upon completion of the training course in addition t o the monthly capitation payment for physicians maintenance dialysis services. If the training period is not completed, such as in instances where the patient can no longer be trained, prorate the training rate in proportion to the number of training trea tments completed, but not to exceed $500. For purposes of this pro- ration, consider 25 training treatments as a complete course of training. Therefore, for an incomplete training course, pay the physician for the training services based on an amount of $20 per treatment times the number of treatments completed. This rule applies to all modes of treatment, including CAPD.   Occasionally, it is necessary to furnish additional training to an ESRD self -dialysis beneficiary after the initial training course is co mpleted; e.g., because of a change from hemodialysis to peritoneal dialysis, a change in equipment. The amount of additional training required depends upon the transferability of the skills the patient has already learned; subsequent training would normall y be very limited. Physicians training services furnished during subsequent training of an ESRD beneficiary are covered and reimbursed in addition to the initial training fee.   Subsequent training sessions that are reimbursable under this rule must be dis tinguished from the ongoing services for which the original training fee is considered payment in full; e.g., answering the patients questions arising after home dialysis has begun about the machine the patient has already been trained to use. No addition al payment is made after the initial training course unless the subsequent training is required because of a change from the patients treatment machine to a machine that he had not been trained to use in the initial training course, a change in the type of dialysis, or a change in setting or dialysis partner.   160 - Payment for Physicians Services Furnished to Dialysis Inpatients  (Rev. 1, 10- 01-03)  The following instructions cover physicians services to inpatients for all types of dialysis patients; e.g. , hemodialysis, intermittent peritoneal dialysis (IPD), continuous ambulatory peritoneal dialysis (CAPD), and continuous cycling peritoneal dialysis (CCPD). Note that the hospitalization need not be related to dialysis.   Payment is made on the claim only if the place of service on the claims is inpatient hospital.  See 170 for proper HCPCS coding.   160.1 - Determining Whether Physician Services Furnished on Day of Dialysis (Rev. 1, 10- 01-03)  If the patient is admitted to a hospital to receive dialysis for a reason not related to the patients ESRD condition (e.g., there was no space available in the dialysis unit), the dialysis is covered as an outpatient service.  In this case, A/B MACs (B) do not pay separately for any p hysicians ESRD services because these services are covered under the physicians MCP or under the add -on to the hospitals composite rate for physicians under the initial method.  (See 130.1 for a description of the initial method.)   160.2 - Physicians Services Furnished on Day of Dialysis (Rev. 1, 10- 01-03) B3-15062.1  Supervision or direction of a dialysis treatment by a physician does not ordinarily meet the requirements for physicians services and, therefore, is not paid for as such under the fee schedule. However, physicians are responsible for the medical care and treatment of the dialysis patients. Physicians services furnished to those patients that meet the requirements and are medically necessary are covered. The hospital medical record must document the services furnished and the medical reasons for them.   Generally, claims from the physician receiving a procedure code payment for additional services furnished to the same patient on the day of dialysis must  be reviewed by medical staff prior to payment. Follow 170.B  for dialysis and evaluation and management services performed on the same day.   Payment in addition to the procedure code payment is made only if the service is  not related to the treatment of the patients ESRD, and the service was not, and could not have been, furnished during the dialysis treatment. However, an exception to this rule is physicians surgical services; e.g., catheter insertion. Physicians surgi cal services are generally billed under the appropriate procedure code for payment. If more than one physician furnishes care to the same dialysis patient, follow the usual coverage rules on concurrent care.   160.3 - Physicians Services Furnished on Non -Dialysis Days (Rev. 1, 10- 01-03)  Physicians services furnished on non- dialysis days are coded and paid under the same rules as any other physicians services when non -renal related services are furnished. Renal -related services may also be paid if the phy sician chooses to prorate the MCP payment. Generally, these services are the physicians hospital visits and are coded and paid as such.   160.4 - Requirements for Payment  (Rev. 1, 10- 01-03)  A.   General   When paying for physicians services furnished to dialysis inpatients, whether they are ESRD patients or acute dialysis patients, there are several factors to consider.    The payment must be for covered physicians services;    The services must be medically necessary; and    The payment for the services must be reasonably related to the nature of the services actually furnished.  B.   Physicians Services -  Criteria for Procedure Codes   The procedure code covers the full range of physicians renal -related services furnished during an inpatient dialysis treatment.   In order to be paid on the basis of a procedure code, the physician must have been physically present with the patient at some time during the course of the dialysis, and the medical record (e.g., the physicians progress note or the nurses notes in the patients hospital medical record) must document this.   If the physician visits the dialysis inpatient on a dialysis day, but not during the dialysis treatment, do not pay the physician on the basis of a procedure code. The nature of these servi ces is the same as physicians services furnished to any inpatient during a hospital visit. Therefore, use the same hospital visit codes that apply to any other physicians treating hospital inpatients.   Physicians services furnished to patients who are di alyzed as inpatients because there is no room in the outpatient dialysis units are covered under the MCP, and physicians are not paid amounts in addition to or in place of the MCP.   Effective January 1, 1995, all evaluation and management services provided on the same day as inpatient dialysis codes should be denied without review with the exception of CPT codes 99221- 99223, 99251- 99255, and 99238. These codes may be billed with modifier  -25 and reviewed for possible allowance if the evaluation and manage ment service is unrelated to the treatment of ESRD and was not and could not have been furnished during the dialysis treatment.   C.   Peritoneal Dialysis   Peritoneal dialysis is typically furnished in extended periods. For example, CAPD is continuous, and the patient may actually be dialyzed seven days per week. IPD may be furnished in extended periods of 30 hours or more. The fact that a patient is dialyzed continuously for an extended period does not justify payment in excess of the average weekly allowan ce made for hemodialysis services. Payment in excess of this amount is made only if it is determined that the same kind and intensity of physicians hemodialysis treatment beyond the number ordinarily furnished in a 7- day period, and the patients condition was similar to that of a hemodialysis patient who would have required these additional services.   170 - Billing Physician Dialysis Services (codes 90935 - 90999) and Related Payment  (Rev. 1, 10- 01-03)  Except when the MCP applies claims for physicians i npatient dialysis services furnished to ESRD or acute dialysis patients are processed using physicians inpatient dialysis services procedure codes 90935, 90937, 90945, and 90947. All A/B MACs (B) must use these codes for these services.   A/B MACs (B) make  payment on the basis of ESRD procedure codes, i.e., codes 90935, 90937, 90945, or 90947, only if the place of service on the claim is inpatient hospital. This is because all physicians outpatient renal -related services are included in payment made under the monthly capitation payment.   A. ESRD Monthly Capitation Payments   Effective January 1, 1995, monthly capitation payments are made under the physician fee schedule. For their adult patients, physicians may bill either the monthly code (CPT code 90921) or the daily code (CPT code 90922) with units that represent the number of days in a single month, but may not bill both.  To bill for a month of services for pediatric patients, providers should bill the appropriate monthly code (CPT codes 90919, 90920, or  90921). To bill for less than a month of service, providers bill the appropriate daily code (CPT codes 90923- 90925) and units that represent the number of days. Providers may bill either the monthly code or the daily code, but not both. Since billing is done at the conclusion of the month, the patients age at the end of month is the age of the patient for billing purposes.   B - Inpatient and Outpatient Dialysis Services On Same Date As An Evaluation and Management Service   CPT codes 90935 and 90937 are used to report inpatient ESRD hemodialysis and outpatient hemodialysis performed on non- ESRD patients (e.g., patients in acute renal failure requiring a brief period of dialysis prior to recovery). CPT codes 90945 and 90947 are used to report all non-hemodialysis procedures. All four of these codes include payment for any evaluation and management services related to the patients renal disease that are provided on the same date as the dialysis service. Therefore, payment for al l evaluation and management services is bundled into the payment for 90935, 90937, 90945, and 90947, except for the following evaluation and management services which may be reported on the same date as a dialysis service with the use of the 25 modifier and they are significant and separately identifiable and met any medical necessity requirements:   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)