(Medicare Benefit Policy Manual)

Once the patient is trained, CAPD is primarily a home service because the patient performs CAPD 24 hours a day.  Therefore, renal dialysis services that are specifically CAPD services are training services and include associated services that are furn ished in the ESRD facility during training.  Persons who are primarily treated by CAPD may also require in -facility dialysis, either intermittent peritoneal or hemodialysis, occasionally.   Prior to the implementation of the ESRD PPS, there were specific fr equency coverage requirements of the routine laboratory services furnished for CAPD.  The CAPD laboratory tests that were included under the composite rate are those monthly tests listed in (20.2.E.1.b of this chapter) and they are covered during training .  The coverage frequency screens for these laboratory tests did not apply during training, as these tests were commonly given during each training session.  All of these tests were included in the training screen, regardless of how frequently they were gi ven, and may have been billed separately.  Under the composite rate, separately billable laboratory tests must have been documented for medical necessity.  However, under the ESRD PPS all renal dialysis laboratory services are included in the bundle regardless of the frequency they are furnished.  Supplemental Dialysis during CAPD Training   It may be necessary to supplement the patients dialysis during CAPD training with intermittent peritoneal dialysis because the patient has not yet mastered the CAPD technique.  Generally, no more than three supplemental intermittent peritoneal dialysis sessions are required during the course of CAPD training, and these may be covered routinely.  If more than three sessions are billed during training, the claims must be documented for medical necessity.  Under certain circumstances, the form of supplemental dialysis may be hemodialysis.   D.  Continuous Cycling Peritoneal Dialysis (CCPD) Training  Continuous cycling peritoneal dialysis training is furnished in sessions of 8  hours per day 5 days per week.  Typically, five exchanges can be performed per day to teach the patient the technique; however, no specific number of exchanges is required.  Most patients are trained within 2 weeks; however, up to 15 sessions may be cover ed routinely.  The A/B MAC (A) will determine whether or not training sessions over 15 are medically necessary.   E.  Retraining   Payment is made for retraining self -dialysis education after a patient or caregiver has completed the initial program if the pa tient continues to be an appropriate candidate for home dialysis.  Most patients receive additional training on the use of new equipment, a change in their caregiver, or a change in modality.  The ESRD facility may not bill for retraining services when the y install home dialysis equipment or furnish monitoring services.  For example, an ESRD facility nurse may not bill for retraining sessions to update treatment records, order new supplies, or add additional medicine for the treatment of infection.  NOTE:   When retraining and educational services are furnished to a patient or caregiver already knowledgeable in some other form of self -dialysis or if training is being done for a change of equipment, fewer sessions are necessary because of the transferability o f certain basic skills.   Criteria for retraining are explained in greater detail in Pub. 100 -04, Medicare Claims Processing Manual, chapter 8, 50.8.   40 - Other Services  (Rev. 200, Issued: 12- 02-14, Effective: 01- 01-15, Implementation: 01- 05-15)  ESRD beneficiaries may receive other services that may be related to their ESRD diagnosis but are excluded from the ESRD PPS payment.  A.  Coverage under the Home Health Benefit for ESRD Patients   Services that are covered under the ESRD PPS are excluded from coverage under the Medicare home health benefit.   Services can be provided to dialysis patients under the home health benefit as long as the condition that necessitates home health care is not a renal dialysis service.  A beneficiary, entitled to Medicare u nder the ESRD program, is eligible for home health benefits as is any other Medicare beneficiary if coverage conditions are met provided the patients condition is not covered by the ESRD PPS.  This is true even where the primary condition is related to ki dney failure.  For example, Medicare will pay for home health care, such as decubitus care or for severe hypotension that is not included in the ESRD PPS.   Medicare patients can receive care under both the ESRD benefit and the home health benefit.  The key  is whether or not the services are being furnished for the treatment of the patients ESRD.  Surgical dressing changes that are furnished for the treatment of ESRD are to be provided by the ESRD facility, but dressing changes furnished for reasons other t han for the treatment of ESRD may be provided under the home health benefit provided all eligibility criteria have been met.  See 42 CFR 409.49(e) .  B.  Coverage under the Hospice Benefit   If the patients terminal condition is not related to ESRD, the patient may receive covered services under both the ESRD benefit and the hospice benefit.  Hospice agencies can provide hospice services to patients who wish to continue dialysis treatment.   C.  Skil led Nursing Facility (SNF) Patients Needing Dialysis Services   Section 4432(b) of the Balanced Budget Act (BBA) requires consolidated billing for SNFs.  Dialysis and certain dialysis -related services including covered ambulance transportation to obtain the  dialysis services are excluded from SNF consolidated billing and the services may be billed separately.  For more information regarding ESRD patients also receiving services in a SNF, see Pub. 100- 02, chapter 8, 10.2 and Pub. 100-04, chapter 6, 20.2.1.   D.  Nursing Homes and/or Long Term Care Facility (LTC) Patients Needing Dialysis Services   Medicare ESRD beneficiaries who permanently reside in a nursing home or LTC facilities and who meet the home dialysis requirements set forth under 42 CFR 494.100 a re considered home dialysis patients.  All home dialysis items and services will be paid under the ESRD PPS and no separate payment will be made to the facility.   E.  Physicians Services for ESRD Beneficiaries   Physician services are excluded from the ESR D PPS.  Payment for physicians services is subject to the guidelines in Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 15, 30.  Medicare pays physicians services furnished in connection with dialysis sessions for outpatients who are on maintenance  dialysis in an ESRD facility or at home by the monthly capitation payment method or the initial method.  See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 8, for payment instructions.  For physician responsibilities, refer to 42 CFR 414.310.  F.  The Sudden Onset of Acute Symptoms During Renal Dialysis Services   Renal dialysis services furnished in other settings, such as declotting of shunts, suture removal, or furnishing renal dialysis drugs may be paid separately only if the services could not have been furnished in the ESRD facility.   Emergency renal dialysis services furnished in a hospital emergency room are separately paid when medical justification is submitted on the claim and when the absence of immediate medical attention in the emergency room could reasonably be expected to result in either:    Placing the patients health in serious jeopardy;   Serious impairment to bodily functions; or   Serious dysfunction of any bodily organ or part.   G.  Renal Dialysis Services Furnished During the Crea tion or Revision of a Vascular Access   The creation or revision of an ESRD patients vascular access is usually performed in hospital outpatient departments.  Laboratory services, drugs and biologicals, and equipment and supplies furnished to ESRD benefici aries for the treatment of ESRD on the day a procedure is performed to create or revise a vascular access site is not considered to be renal dialysis services.  Providers furnishing renal dialysis services that are subject to the ESRD PPS consolidated bill ing requirements during the creation or revision of a vascular access for an ESRD beneficiary should bill those services separately with an AY modifier.  The appropriate HCPCS or CPT code indicating the creation or revision of an access site is required on the claim.  Items and services that are subject to the ESRD PPS consolidated billing requirements may be found at http://www.cms.gov/ESRDPayment/50_Consolidated_Bill ing.asp#TopOfPage .  H.  Noninvasive Vascular Studies for ESRD Patients   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 to determine if the access site is functioning correctly.   An ESRD facility must furnish all necessary services, equipment, and supplies associated with a dialysis treatment, either directly or under arrangements.  The ESRD facility is fi nancially responsible for the service.  If an ESRD facility or a renal physician decides to monitor the patients access site with a non -invasive vascular study and does not have the equipment to perform the procedure, the ESRD facility or physician may ar range for the service to be furnished by another source.  The alternative source, such as an independent diagnostic testing facility must look to the ESRD facility for payment.   Procedures associated with monitoring access may include activities such as, b ut not limited to, taking venous pressure, aspirating thrombus, observing elevated recirculation time, reduced urea reduction ratios, or collapsed shunt, etc.  All such procedures are included under the ESRD PPS.  Non- invasive vascular studies such as dupl ex and Doppler flow scans are not covered as separately billable services if used to monitor a patients vascular access site.   Doppler flow studies may be considered appropriate in the presence of signs or symptoms of possible failure of the ESRD patient s vascular access site, and when the results are used in determining the clinical course of the treatment for the patient.  Routine monitoring by noninvasive Doppler flow studies is included under the ESRD PPS.   Examples supporting the medical necessity fo r Doppler flow studies include:    Elevated dynamic venous pressure >200mm HG when measured during dialysis with the blood pump set on a 200cc/min.,   Access recirculation of 12 percent or greater,    An otherwise unexplained urea reduction ratio <60 percent, a nd   An access with a palpable water hammer pulse on examination, (which implies venous outflow obstruction).  Unless the documentation is provided supporting the 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 define the problem.   This policy is applicable to claims from ESRD facilities and all other sources, such as independent diagnostic testing facilities and hospital outpatient departments.   The professional component of the procedure is included in the MCP.  The professional component is denied if billed by the MCP physician. Medically necessary services that are included or bundled into the MCP (e.g., test interpretations) are separately p ayable when furnished by physicians other than the MCP physician.  The MCP physician is identified by the performing provider number that billed MCP services identified by the HCPCS code 90995.   I.  Nutritional Services   ESRD facilities are required, in ac cordance with 42 CFR 494.80(a)(6) and 494.90(a)(2), to evaluate a patients nutritional status and expected to assist the patient in achieving their nutritional goals by providing education, counseling, and encouragement.  These services are included in the ESRD PPS.  Nutritional items, such as nutritional supplements, are not considered related to the treatment of ESRD and are not included in the ESRD PPS as renal dialysis services.   50 - ESRD Prospective Payment System (PPS) Base Rate  (Rev. 200, Issued:  12-02-14, Effective: 01- 01-15, Implementation: 01- 05-15)  Updates to the provisions under the ESRD PPS are discussed through rulemaking on a yearly basis.  The updates are implemented through Recurring Update Notifications.  A.  Per Treatment Unit of Payment