Article - Billing and Coding: Frequency of Hemodialysis (A55354)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 11,10 Definitions Relating to ESRD,20 Renal Dialysis Items and Services,20.1 Composite Rate Items and Services,20.2 Laboratory Services,20.3 Drugs and Biologicals,20.3.1 Drug Designation Process,20.4 Equipment and Supplies,30 Home Dialysis,30.1 Home Dialysis Items and Services,30.2 Home Dialysis Training,40 Other Services,50 ESRD Prospective Payment System (PPS) Base Rate,60 ESRD PPS Case-Mix Adjustments,70 ESRD PPS Transition Period,80 Bad Debt,100 Payment for Renal Dialysis Services Furnished to Individuals with Acute Kidney Injury (AKI)CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 8, Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims All sectionsCMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Transmittal 1084, Change Request 5039, dated October 27, 2006CMS Manual System, Pub 100-20, One-Time Notification, Transmittal 1849, Change Request 9989, dated May 12, 2017CMS Final Rule CMS-1651-F published November 4, 2016Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Frequency of Hemodialysis L34575.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.This article outlineshow to lineitem bill dialysis sessionsfor End Stage Renal Disease (ESRD) patients. This does not address line item billing forsessions associated with training or other modalities such as peritoneal dialysis. This article does not change any other billing requirements for dialysis claims. Note: This article uses the terms dialysis "session" and "treatment" interchangeably.CMS Internet-Only Manual, Pub 100-04,Medicare Claims Processing Manual, Chapter 8, requires line item billing for all ESRD claims with dates of service (DOS) on or after April 1, 2007. Each dialysis session performed should be reported on a separate line.CMS Internet-Only Manual, Pub100-02,Medicare Benefit Policy Manual, Chapter 11 discusses that ESRD facilities furnishing dialysis treatments in-facility or in the beneficiary's home are paid for up to 3 treatments per week. Payment for additional treatments, defined as any treatments in excess 3 treatments per week, may be considered in addition to the ESRD PPS per treatment payment amount paid for up to 3 treatments per week.For monthly claims submitted with Bill Type 72X and Revenue Codes 0821 and 0881, 3 approaches of billingper lineare available. Based on the Patients Plan of Care (POC), or other available medical documents, the following scheme should be followed when billing sessions. Note: Dialysis sessions in the patient's POC that are not furnished should not be billed.For dialysis sessions that have been furnished 3 times (3X) per week,each line should be 90999 without any modifiers appended. That is, when the hemodialysis prescription is3 times (3X) per week and each session is furnished, all of these sessions should be billed as 90999 (no modifier appended) and they will be paid as routine conventional dialysis up to 13/14 per month.For each dialysis session furnished in addition to 3 sessions per week that do not include medical documentation supporting a reasonable and necessary determination for payment,each line for these sessions should be billed as 90999 CG. Examples of when this couldoccur include short, more frequent treatments furnished for the convenience of the patient or staff, etc. Additional sessions need to be billed as 90999 CG when medical documentation has not been submitted to support the extra sessions as reasonable and necessary. The CG modifier indicates that the facility attests the additional treatment is not reasonable and necessary andshould not receive additional payment. Each line billed as 90999 CG will be denied. However the use of the modifier is used for data analysis.Please refer to Change Request 9989, Implementation of Modifier CG for Type of Bill 72X, dated May 12, 2017.For eachdialysis session furnished in addition to 3 sessions per week that includes medical documentation supporting areasonable and necessary determination for payment,each line for these sessions should be billed as 90999 KX. These include medical conditions for acute and occasionally chronic conditions that have supporting documentation that the extra sessions are reasonable and necessary (e.g., through documents from recent hospital care, office visits, dialysis progress notes or MCP visits). These sessions must be reasonable and necessary for additional payment based on clinical conditions. On these claims, the 90999 lines without a modifier will be paid as 3X per week and those lines with 90999 KX will be considered for additional payments. Omission of the KX modifier will result in no additional payment for the lineitem. For diagnoses not listed in this article but felt to be reasonable and necessary, the KX modifier should be appended as well. A denial will occur on these lines, but the redetermination process (an appeal) will be available to submit supportive documentation for review.The expectation is that these 3 scenarios will be seen on monthly claims, i.e., claims with 90999 lines only, or those with lines of 90999 mixed with 90999 CG or KX modifier appended. Ongoing data analysis may trigger provider specific requests for documentation should unusual patterns occur, i.e., claims with only lines of 90999 KX submitted.Please note that the POC and other supporting medical documentation to justify any of the line item sessions will be most important and may be requested.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.The medical record documentation must support the medical necessity of the services as stated in the related policy.Please see L34575 for instructions when clinical conditions outside those listed in the available diagnoses should occur.Please see L34575 for additionalDocumentation RequirementsandUtilization Guidelines.