(Medicare Claims Processing Manual)

Payment for renal -related physicians services to ESRD patients is made in either of the following ways:    Under the Monthly Capitation Payment (MCP) (see 140 below for an explanation of the MCP); or    Using the daily codes for ESRD services (CPT codes 90922- 90925) with units that represent the number of days services were furnished.   Under the Initial method (IM)   The A/B MAC (B) receives bills from physicians for services furnished ESRD beneficiaries.   The A/B MAC ( A) receives bills from ESRD facilities.   Lab bills from CLIA certified independent dialysis facilities were billed to the A/B MAC (B) before September 1, 1997, and to the A/B MAC (A) beginning on that date. Other certified labs bill the A/C MAC (B).   130.1 - Initial Method for Physicians Services to Maintenance Dialysis Patients  (Rev. 1, 10- 01-03)  Under the Initial Method (IM), do not pay for physicians routine professional dialysis services. Instead, the dialysis facilitys A/B MAC (A) pays the dialysis  facility for them as part of the facilitys composite rate. Physicians professional services that are not routine professional dialysis services are billed to the contractor and paid in the same way as any other Medicare covered physician professional service.   1.   For the physician to be paid under the IM, the following requirements must be met:   All physicians of the facility must choose the IM with respect to all of the patients treated at the facility and all of the facilitys Method I home dialysis patients. (See 70.1 for a description of Method I). All of the facilitys physicians must file a written statement with their A/B MAC (B) and the facilitys A/B MAC (A) to this effect. For example:  The physicians practicing at ________________ dialysis facility are listed below. The signature of each physician indicates the physicians election to be paid for their routine professional dialysis services under the Initial Method. This election is effe ctive for services furnished beginning with the second month after the month in which this statement is filed with the A/B MAC (B) and the facilitys A/B MAC (A).   This written statement must be signed and dated by each physician.   2.   The physician may bill the A/B MAC (B) only those physicians professional services that are not routine professional dialysis services. (See paragraph 3 below).   The election of the IM is effective for services furnished beginning with the second calendar month after the m onth in which all the physicians of a facility elect it. A physician may terminate the election by written notice to the A/B MAC (B) and to the facilitys A/B MAC (A) that the physician thereby terminates the IM. If the A/B MAC (B) and the A/B MAC (A) rece ive the termination notice on or before November 1, it is effective the following January 1. If the A/B MAC (B) or the A/B MAC (A) receives it after November 1, it is effective January 1 of the second year after the calendar year in which the notice of ter mination is received. Note that if the IM is terminated by one physician, it is thereby terminated for all physicians at the same facility with respect to the patients treated through that facility.   3.   Definitions   A.   Administrative Services   Physicia n services that are differentiated from routine professional services and other physician services. They include supervision, as described in the definition of supervision of staff, are not related directly to the care of an individual patient and are supportive of the facility as a whole and of benefit to patients in general. Examples of administrative services include supervision of staff, staff training, participation in staff conferences and in the management of the facility, and advising staff on the  procurement of supplies.  B.   Dialysis Session   The period of time that begins when the patient arrives at the facility and ends when the patient departs from the facility. In the case of home dialysis, the period begins when the patient prepares for dia lysis and generally ends when the patient is disconnected from the machine. In this context, a dialysis facility includes only those parts of the building used as a facility. It does not include any areas used as a physicians private office.   C.   Medical  Direction   Routine professional service that entails substantial direct involvement and the physical presence of the physician in the delivery of services directly to the patient.   D.   Routine Professional Services   Physicians services furnished during a dialysis session and all services listed under Types of routine professional services that:    Are personally furnished by a physician to an individual patient.  Contribute directly to the diagnosis or treatment of an individual patient.  Ordinarily must be performed by a physician.   E.   Supervision of Staff   Administrative services that do not necessarily require the physician to be present at the dialysis session. It is a general activity primarily concerned with monitoring performance of and giving gui dance to other health care personnel (such as nurses and dialysis technicians) who deliver services to patients.   F.   Types of Routine Professional Services   Routine professional services include at least the following services when medically appropriate:    Visits to the patient during dialysis, and in conjunction with review of laboratory test results,    Nurses notes and any other medical documentation, as a basis for:   o Adjustment of the patients medication, diet or the dialysis procedure;   o Prescription of medical supplies; and  o Evaluation of the patients psychosocial status and the appropriateness of the modality,   o Medical direction of staff in delivering services to a patient during a dialysis session, and   o Pre-dialysis and post -dialysis examinations o r examinations that could have been furnished on a pre -dialysis or post -dialysis basis.   140 - Monthly Capitation Payment Method for Physicians Services Furnished to Patients on Maintenance Dialysis  (Rev. 1456, Issued: 02- 22-08, Effective: 03- 24-08, Imple mentation: 03 -24-08)  Physicians and practitioners managing patients on dialysis (center based) are paid a monthly capitation payment (MCP) for most outpatient dialysis -related physician services furnished to a Medicare end stage renal disease (ESRD) benef iciary.  The payment amount varies based on the number of visits provided within each month and the age of the ESRD beneficiary.  Physicians and practitioners managing ESRD patients who dialyze at home are paid a single monthly rate based on the age of the ESRD beneficiary, regardless of the number of face -to-face physician or practitioner visits.  The MCP is reported once per month for services performed in an outpatient setting that are related to the patients ESRD.   Physicians and practitioners may receive payment for managing patients on dialysis for less than a full month of care in specific circumstances as discussed in section 140.2.  Payment for ESRD related services, less than a full month, is made on a per diem bases.   Payment for ESRD -related ser vices is made at 80 percent of the Medicare approved amount (lesser of the actual charge or applicable Medicare fee schedule amount) after the beneficiarys Part B deductible is met. The beneficiary is responsible for the Part B deductible and the 20 perce nt coinsurance for physician and practitioner ESRD -related services.   A.  Services Included in Monthly Capitation Payment   The following physician services are included in the MCP:    Assessment of the need for a specified diet and the need for nutritional supplementation for the control of chronic renal failure. Specification of the quantity of total protein, high biologic protein, sodium, potassium, and amount of fluids to be allowed during a given time period. For diabetic patients with chronic renal fail ure, the prescription usually specifies the number of calories in the diet.   Assessment of which mode(s) of chronic dialysis (types of hemodialysis or peritoneal dialysis) are suitable for a given patient and recommendation of the type(s) of therapy for a given patient.   Assessment and determination of which type of dialysis access is best suited for a given patient and arrangement for creation of dialysis access.    Assessment of whether the patient meets preliminary criteria as a renal transplant candidate and presentation of this assessment to the patient and family.    Prescription of the parameters of intradialytic management. For chronic hemodialysis therapies, this includes the type of dialysis access, the type and amount of anticoagulant to be employed, blood flow rates, dialysate flow rate, ultrafiltration rate, dialysate temperature, type of dialysate (acetate versus bicarbonate) and composition of the electrolytes in the dialysate, size of hemodialyzer (surface area) and composition of the dialyzer mem brane (conventional versus high flux), duration and frequency of treatments, the type and frequency of measuring indices of clearance, and intradialytic medications to be administered. For chronic peritoneal dialysis therapies, this includes the type of peritoneal dialysis, the volume of dialysate, concentration of dextrose in the dialysate, electrolyte composition of the dialysate, duration of each exchange, and addition of medication to the dialysate, such as heparin, and the type and frequency of measuri ng indices of clearance. For diabetics, the quantity of insulin to be added to each exchange is prescribed.    Assessment of whether the patient has significant renal failure -related anemia, determination of the etiology(ies) for the anemia based on diagnost ic tests, and prescription of therapy for correction of the anemia, such as vitamins, oral or parenteral iron, and hormonal therapy such as erythropoietin.   Assessment of whether the patient has hyperparathyroidism and/or renal osteodystrophy secondary to chronic renal failure and prescription of appropriate therapy, such as calcium and phosphate binders for control of hyperphosphatemia. Based upon assessment of parahormone levels, serum calcium levels, and evaluation for the presence of metabolic bone dise ase, the physician determines whether oral or parenteral therapy with vitamin D or its analogs is indicated and prescribes the appropriate therapy. Based upon assessment and diagnosis of bone disease, the physician may prescribe specific chelation therapy with deferoxamine and the use of hemoperfusion for removal of aluminum and the chelation.    Assessment of whether the patient has dialysis -related arthropathy or neuropathy and adjustment of the patients prescription accordingly. Referral of the patient for any additional needed specialist evaluation and management of these end -organ problems.    Assessment of whether the patient has fluid overload resulting from renal failure and establishment of an estimated ideal (dry) weight. The physician determines the need for fluid removal independent of the dialysis prescription and implements these measures when indicated.    Determination of the need for and prescription of antihypertensive medications and their timing relative to dialysis when the patient is hypertensive in spite of correction of fluid overload.   Periodic review of the dialysis records to ascertain whether the patient is receiving the prescribed amount of dialysis and ordering of indices of clearance, such as urea kinetics, in order to ascertain whether the dialysis prescription is producing adequate dialysis. If the indices of clearance suggest that the prescription requires alteration, the physician orders changes in the hemodialysis prescription, such as blood flow rate, dialyzer surface area, dia lysis frequency, and/or dialysis duration (length of treatment). For peritoneal dialysis patients, the physician may order changes in the volume of dialysate, dextrose concentration of the dialysate, and duration of the exchanges.   Periodic visits (at least one per month) to the patient during dialysis to ascertain whether the dialysis is working well and whether the patient is tolerating the procedure well (physiologically and psychologically). During these visits, the physician determines whether alte ration in any aspect of a given patients prescription is indicated, such as changes in the estimate of the patients dry weight. Review of the treatment with the nurse or technician performing the therapy is also included. The frequency of these visits wi ll vary depending upon the patients medical status, complicating conditions, and other determinants.   Performance of periodic physical assessments, based upon the patients clinical stability, in order to determine the necessity for alterations in various  aspects of the patients prescription. Similarly, the physician reviews the results of periodic laboratory testing in order to determine the need for alterations in the patients prescription, such as changes in the amount and timing of phosphate binders or dose of erythropoietin.   Periodic assessment of the adequacy and function of the patients dialysis access appropriate tests and antibiotic therapy.    Interpretations of the following tests:   o Bone mineral density studies (CPT codes 76070, 76075, 78350, a nd 78351);   o Noninvasive vascular diagnostic studies of hemodialysis access (CPT codes 93925, 93926, 93930, 93931, and 93990);   o Nerve conduction studies (CPT codes 95900, 95903, 95904, 95925, 95926, 95927, 95934, 95935, and 95936);   o Electromyography studies  (CPT codes 95860, 95861, 95863, 95864, 95867, 95867, 95869, and 95872).