(Medicare Claims Processing Manual)

In order to furnish covered CAPD services, a facility must be a Medicare approv ed ESRD facility and must meet additional standards established by CMS.   However, in rare instances an ESRD patient may require a combination of dialysis techniques, on the same day, in order to achieve satisfactory results.  In these situations, Medicare pays for both types of dialysis services furnished on the same day.  Medicare A/B MACs (A) determine the medical necessity.  In each case the A/B MAC (A) obtains medical documentation from the facility that supports the use of back- up dialysis with another  treatment modality.  If a CAPD patient frequently requires back- up sessions, the A/B MAC (A)s medical staff may request medical records to determine if this is the appropriate mode of treatment to meet medical necessity requirement for payment purposes a nd/or whether a different mode of treatment is more advantageous to the beneficiary.   50.6.2 - Payment for Hemodialysis Sessions  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  Hemodialysis is typically furnished three times per  week in sessions of three to five hours duration. Each hemodialysis session equals one PPS base  rate payment.  Therefore, three sessions per week is three PPS base rate payments.  Dialysis furnished at this frequency is paid without the need for a secondary diagnosis to justify payment.  The justification must support the medical necessity of the service(s) being rendered.   50.7 - Ultrafiltration  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)   Ultrafiltration (revenue co de 0881) is a process for removing excess fluid from the blood through the dialysis membrane by means of pressure. It is not a substitute for dialysis. Ultrafiltration is used in cases where excess fluid cannot be removed easily during the regular course o f hemodialysis. It is commonly done during the first hour or two of hemodialysis on patients who, for example, have refractory edema.   Pre-dialysis Ultrafiltration -  While the need, if any, for pre -dialysis ultrafiltration varies from patient to patient, the facilitys PPS rate  covers the full range of complicated and uncomplicated outpatient dialysis treatments. Therefore, no additional charge is recognized for pre -dialysis ultrafiltration.   Separate Ultrafiltration -  Occasionally, medical complications require that ultrafiltration be performed at a time other than when a dialysis treatment is given, and in these cases an additional payment may be made. However, the need for separate ultrafiltration must be documented in the medical record and a supporting other diagnosis must be included on the claim.   50.8 - Training and Retraining  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  See Pub. 100- 02 Medicare Benefit Policy Manual, Chapter 11, for coverage rules for dialysis training.   Training services and supplies that are covered under the Prospective Payment System (PPS) base rate includes personnel services, dialysis supplies and parenteral items used in dialysis, written training manuals, material and laboratory tests.    End Stage Renal Disease Prospective Payment System (ESRD PPS)  claims with dates of service on or after January 1, 2011, billing for dialysis training sessions will receive a home dialysis training add -on payment.    The home dialysis training add- on paym ent  is adjusted by the geographic area wage index  and added to the PPS base rate. The home dialysis training add- on payment that accounts for nursing time for training treatments. The home dialysis training add -on payment applies to both peritoneal dialys is (PD) and hemodialysis ( HD) training treatments.  Updates to the home dialysis training add- on payment are published through rulemaking .  Hemodialysis (HD)  Training (082X):  An ESRD facility may bill a maximum of 25 training sessions per patient for hemodialysis training.   Intermittent Peritoneal Dialysis (IPD) Training (083X):  An ESRD facility is not reimbursed for more three IPD treatments in a single week, for a total duration longer than 3 months.  Continuous Ambulatory Peritoneal Dialysis (CAPD) Train ing (84X):  An ESRD facility may bill a maximum of 15 training sessions per patient for CAPD training.  The A/B MAC (A) will make a determination whether or not to permit training sessions in excess of 15.   Continuous Cycling Peritoneal Dialysis (CCPD) Training (085X):  An ESRD facility may bill a maximum of 15 training sessions per patient for CCPD training. The A/B MAC (A) will determine whether or not training sessions over 15 are medically necessary.   Retraining   A. General -  Occasionally, it is necessary to furnish additional training to an ESRD self-dialysis beneficiary after the initial training course is completed.  Retraining sessions are paid under the following conditions:    The patient changes from one mode of dialysis to another, e.g., from hemodial ysis to CAPD;   The patients home dialysis equipment changes;   The patients dialysis setting changes;   The patients dialysis partner changes; or   The patients medical condition changes e.g., temporary memory loss due to stroke, physical impairment.   The pa tient must continue to be an appropriate patient for self -dialysis.   B. Payment Rates -  Retraining sessions are reimbursed at the same rate as the facilitys training rate.   C. Duplicate Payments  - No home dialysis training add- on payment is made for a home dialysis treatment furnished on the same day as a retraining session.  In the case of a CAPD patient, the facilitys equivalent CAPD daily rate is not paid on the day(s) of retraining.   50.9 - Coding for Adequacy of Dialysis, Vascular Access and Infection  (Rev. 10640, Issued:08- 06-21, Effective:09- 07-21, Implementation:09- 07-21)  A.   Reporting the Urea Reduction Ratio (URR) for End Stage Renal Disease (ESRD ) Hemodialysis Claims   All hemodialysis claims must indicate the most recent Urea Reduction Ratio (URR) for the dialysis patient.  Code all claims using HCPCS code 90999 along with the appropriate G modifier listed in section B.   Claims for dialysis treatments must include the adequ acy of hemodialysis data as measured by URR.  Dialysis facilities must monitor the adequacy of dialysis treatments monthly for facility patients.  Home hemodialysis and peritoneal dialysis patients may be monitored less frequently, but not less than quarte rly.  If a home hemodialysis patient is not monitored during a month, the last, most recent URR for the dialysis patient must be reported.   HCPCS code 90999 (unlisted dialysis procedure, inpatient or outpatient) must be reported in field location 44 for al l bill types 72X.  The appropriate G -modifier in field location 44 (HCPCS/RATES) is used, for patients that received seven or more dialysis treatments in a month.  Continue to report revenue codes 0820, 0821, 0825, and 0829 in field location 43.  G1 - Most  recent URR of less than 60%  G2 - Most recent URR of 60% to 64.9%  G3 - Most recent URR of 65% to 69.9%  G4 - Most recent URR of 70% to 74.9%  G5 - Most recent URR of 75% or greater   For patients that have received dialysis 6 days or less in a month, facilities use the following modifier:   G6 - ESRD patient for whom less than seven dialysis sessions have been provided in a month.  For services beginning January 1, 2003, and after, if the modifier is not present, A/B/MACs (A) must return the claim to the provid er for the appropriate modifier.  Effective April, 2007 due to the requirement of line item billing, at least one revenue code line for hemodialysis on the claim must contain one of the URR modifiers shown above.  The URR modifier is not required on every hemodialysis line on the claim.   The techniques to be used to draw the pre - and post -dialysis blood urea Nitrogen samples are listed in the National Kidney Foundation Dialysis Outcomes Quality Initiative Clinical Practice Guidelines for Hemodialysis Adequacy, Guideline 8, Acceptable Methods for BUN sampling, New York, National Kidney Foundation, 2000, pp.53- 60.  B.   Reporting the Vascular Access for End Stage Renal Disease (ESRD)  Hemodialysis Claims   ESRD claims for hemodialysis with dates of service on or  after July 1, 2010 must indicate the type of vascular access used for the delivery of the hemodialysis at the last hemodialysis session of the month.  One of the following codes is required to be reported on the latest line item date of service billing fo r hemodialysis revenue code 0821.  It may be reported on all revenue code 0821 lines at the discretion of the provider.   Note:   Modifier V5 must be entered if a vascular catheter is present even if it is not being used for the delivery of the hemodialysis.  In this instance 2 modifiers should be entered, V5 for the vascular catheter and either V6 or V7 for the access that is being used for the delivery of hemodialysis.   Modifier V5  - Any Vascular Catheter (alone or with any other vascular access),   Modifier V6  - Arteriovenous Graft (or other Vascular Access not including a vascular catheter in use with two needles)   Modifier V7  - Arteriovenous Fistula Only (in use with two needles)   C.   Reporting the Kt/V for ALL End Stage Renal Disease (ESRD ) Claims   All End Stage Renal Disease (ESRD) claims with dates of service on or after July 1, 2010 must indicate the applicable Kt/V reading for the dialysis patient.  The reading result and the date of the reading must be reported on the claim using the following claim  codes:   Value Code D5  Result of last Kt/V reading.  For in -center hemodialysis patients this is the last reading taken during the billing period.  For peritoneal dialysis patients and home hemodialysis this may be before the current billing period but s hould be within 4 months of the claim date of service.    Hemodialysis : For in -center and home -hemodialysis patients prescribed for three or fewer treatments per week, the last Kt/V obtained during the month must be reported.  Facilities must report single p ool Kt/V using the preferred National Quality Forum (NQF) endorsed methods for deriving the single pool Kt/V value: Daugirdas II or Urea Kinetic Modeling (UKM). The reported Kt/V should not include residual renal function.   A value of 8.88 shall be entere d on the claim if the situation exists that a patient is prescribed and receiving greater than three hemodialysis treatments per week for a medically justified and documented clinical need.  The 8.88 value is not to be used for patients who are receiving  extra treatments for a temporary clinical need (e.g. fluid overload).  A medical justification must be submitted for patients receiving greater than 13 treatments per month.    Peritoneal Dialysis :  When measured the delivered weekly total Kt/V (dialytic and residual) should be reported.   This code is effective and required on all ESRD claims with dates of service on or after July 1, 2010.  In the event that no Kt/V reading was performed providers must report the D5 with a value of 9.99.