evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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:
(Medicare Claims Processing Manual)
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)  For Medicare coverage of noninvasive vascular studies, see the Medicare Benefit Policy Manual, Chapter 11.  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, and when occlusions occur, either declot the access or refer the patient for appropriate treatment.  Procedures associated with monitoring access involve taking venous pressure, aspirating thrombus, observing elevated recirculation time, re duced urea reduction ratios, or collapsed shunt, etc.  All such procedures are covered under the composite rate.   ESRD facilities may not monitor access through noninvasive vascular studies such as duplex and Doppler flow scans and bill separately for these procedures.  Noninvasive vascular studies are not covered as a separately billable service if used to monitor a patients vascular access site.   Medicare pays for the technical component of the procedure in the composite payment rate.
(Medicare Claims Processing Manual)
Medicare pays for the technical component of the procedure in the composite payment rate.  Where there are si gns and symptoms of vascular access problems, Doppler flow studies may be used as a means to obtain diagnostic information to permit medical intervention to address the problem.  Doppler flow studies may be considered medically necessary in the presence of  signs or symptoms of possible failure of the ESRD patients vascular access site, and when the results are used in determining the clinical course of the treatment for the patient.   The only Current Procedural Terminology (CPT) billing code for noninvasive vascular testing of a hemodialysis access site is 93990.  A/B MACs (B) must deny separate billing of the technical component of this code if it is performed on any patient for whom the ESRD composite rate for dialysis is being paid, unless ther e is appropriate medical indication of the need for a Doppler flow study.   When a dialysis patient exhibits signs and symptoms of compromise to the vascular access site, Doppler flow studies may provide diagnostic information that will determine the appropriate medical intervention.  Medicare considers a Doppler flow study medically necessary when the beneficiarys dialysis access site manifests signs or symptoms associated with vascular compromise, and when the results of this test are necessary to determi ne the clinical course of treatment.   Examples supporting the medical necessity for Doppler flow studies include:   a. Elevated dynamic venous pressure >200mm HG when measured during dialysis with the blood pump set on a 200cc/min.,   b. Access recirculation  of 12 percent or greater,   c. An otherwise unexplained urea reduction ration <60 oercebtm abd   d. An access with a palpable water hammer pulse on examination, (which implies venous outflow obstruction).  Unless the documentation is provided supporting t he necessity of more than one study, Medicare will limit payment to either a Doppler flow study or an arteriogram (fistulogram, venogram), but not both.
(Medicare Claims Processing Manual)
Unless the documentation is provided supporting t he 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 further define the extent of the problem.  The patients medical record(s) must provide documentation supporting the need for more than one imaging study.   This policy is applicable to claims from ESRD facilities and all other sources, such as independent diagnostic testing facilities, and hospital outpatient departments.  A/B MACs (B) shall develop  LMRP for Doppler flow studies if this service meets the criteria listed in the Medicare Program Integrity Manual, Chapter 1.  This provides guidance to contractors on the scope, purpose, and meaning of LMRP.  The professional component of the procedure is  included in the monthly capitation payment (MCP) (See 140 above.) The professional component should be denied for code 93990 if billed by the MCP physician.  Medically necessary services that are included or bundled into the MCP (e.g., test interpretations) are separately payable when furnished by physicians other than the MCP physician.  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Four.   Group Code: CO  CARC: 24  RARC: N/A  MSN:16.32  Billing for monitoring of hemodialysis access using CPT codes for noninvasive vascular studies other than 93990 is considered a misrepre sentation of the service actually provided and contractors will consider this action for fraud investigation.  They will conduct data analysis on a periodic basis for noninvasive diagnostic studies of the extremities (including CPT codes 93922, 93923, 93924, 93925, 93926, 93930, 93931, 93965, 93970, 93971).  Contractors should handle aberrant findings under normal program safeguard processes by taking whatever corrective action is deemed necessary.   190 - Appeal Rights for Denied Claims
(Medicare Claims Processing Manual)
190 - Appeal Rights for Denied Claims   For appeal rights i f the claim is denied see Chapter 29.   200  Utilization of REMIS for A/B MAC (B) Claims Adjudication  (Rev. 82, 02- 06-04)  Renal Management Information System (REMIS) determines the Medicare coverage periods for ESRD patients and serves as the primary mechanism to store and access information in the ESRD Program Management and Medical Information System Database.  REMIS is used by CMS and the renal community to monitor the Medicare status, transplant activities, dialysis activities, and Medicare utiliza tion of ESRD patients and their Medicare provider.   The following fields are contained in the (Dialysis) auxiliary file:    ESRD Coverage Start Date  (The date on which the beneficiary is entitled to Medicare, in some part, because of a diagnosis of End Stage  Renal Disease.)    ESRD Coverage Source Code (The source of the information that establishes Medicare- based End- Stage Renal Disease Coverage; A= Part A and Dialysis Training, B= Part A and Dialyzing (No 3 month wait), C= Part A and 3 months after Dialysis, D= Part A and Functioning Transplant, E= Part A and Month of Pre-Transplant Stay, F= Part A and ESRD (Verified Source), Blank= No ESRD Involvement.)    ESRD Coverage Termination Date  (The date on which the beneficiary is no longer entitled to Medicare under ESRD Provisions.)    ESRD Coverage Termination Reason (A code that indicates the reason Medicare- based End- Stage Renal Disease Coverage was terminated; codes: A= Month of transplant plus 36 months, B=Last month of chronic dialysis, C= Part A termination, D=D eath, E=ESRD ended: other verified source.)    ESRD Dialysis Start Date  (A date that indicates when ESRD dialysis started.)    ESRD Dialysis Stop Date  (A date that indicates when ESRD dialysis ended.)    ESRD Transplant Start Date (A date that indicates when a k idney transplant operation occurred.)    ESRD Transplant Stop Date (A date that indicates when a kidney transplant failed.)
(Medicare Claims Processing Manual)
 ESRD Transplant Start Date (A date that indicates when a k idney transplant operation occurred.)    ESRD Transplant Stop Date (A date that indicates when a kidney transplant failed.)    The above data elements are in CWF and stored in the dialysis auxiliary file, which can be used to identify a beneficiarys ESRD eli gibility.  This data source will assist carriers in reviewing overpayment determination and accurately processing claims.  Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR #  R10640CP  08/06/2021 Update of Internet Only Manual (IOM), Pub. 100-04, Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims  09/07/2021 12079 R10236CP 07/31/2020 Update to the IOM Publication (Pub) 100-04, Medicare Claims Processing Manual, Chapters 1, 6, 8, 17, 20, 22, 24, and 31 Referencing the Active Universal Resource Locators (UR Ls) for the Washington Publishing Company (WPC) and the ASC X12 Organizations, and Updates to the HIPAA Eligibility Transaction System (HETS)  08/31/2020 11857 R4202CP 01/18/2019 Update to Pub. 100-04 Chapters 8, 20, and 24 to Provide Language-Only Changes for the New Medicare Card Project  02/19/2019 10964 R4105CP 08/03/2018 System Changes to Implement Epoetin Alfa Biosimilar, Retacrit for End Stage Renal Disease (ESRD) and Acute Kidney Injury (AKI) Claims  01/07/2019 10839 R4010CP 03/23/2018 Revisions to Medicare Claims Processi ng Manual for End Stage Renal Disease  06/26/2018        10541  R3650CP  11/10/2016 Updates to Pub. 100-04, Chapters 8, 13 and 14 to Correct Remittance  Advice Messages  02/10/2016 9841 R3311CP 08/06/2015 End Stage Renal Disease (ESRD) Home Dialysis Policy  09/08/2015 9265 R3139CP 12/02/2014 Implementation of Changes in the End-Stage Renal Disease Prospective Payment System (ESRD PPS) for Calendar Year (CY) 2015 01/05/2015 8978 R3125CP
(Medicare Claims Processing Manual)
12/02/2014 Implementation of Changes in the End-Stage Renal Disease Prospective Payment System (ESRD PPS) for Calendar Year (CY) 2015 01/05/2015 8978 R3125CP 11/14/2014 Implementation of Changes in the End-Stage Renal Disease Prospective Payment System (ESRD PPS) for Calendar Year 01/05/2015 8978 Rev #  Issue Date  Subject  Impl Date  CR #  (CY) 2015   Rescinded and replaced by Transmittal 3139  R3116CP  11/06/2014 Elimination of the 50/50 Payment Rule for Laboratory Services on End Stage Renal Disease (ESRD) Claims  04/06/2015 8957 R3053CP 08/28/2014 Update to Pub. 100- 04, Chapters 7 and 8 to Provide Language -Only Changes for Updating ICD-10 and ASC X12 09/30/2014 8579 R2905CP  03/14/2014 Update to Pub. 100- 04, Chapters 7 and 8 to Provide Language -Only Changes for Updating ICD -10 and ASC X12   Rescinded and replaced by Transmittal 3053 10/01/2014 8579 R2839CP  12/13/2013 Implementation of Changes in the End -Stage Renal Disease Prospective Payment System (ESRD PPS) for Calendar Year (CY) 2014  01/06/2014 8472 R2831CP 11/29/2013 Implementation of Changes in the End -Stage Renal Disease Prospective Payment System (ESRD PPS) for Calendar Year (CY) 2014  Rescinded and replaced by Transmittal 2839  01/06/2014 8472 R2688CP 04/26/2013 Repo rting End Stage Renal Disease (ESRD) Drugs Administered Through the Dialysate  07/01/2013 8256 R2545CP  01/31/2013 Changes Applicable to the Billing of D rugs on ESRD Claims  07/012013 8174 R2582CP  11/02/2012 New Erythropoietin Stimulating Agent (ESA) Peginesatide  Requirements for End Stage Renal Disease (ESRD)  04/01/2013 8050 R2577CP
(Medicare Claims Processing Manual)
11/01/2012 Update to the Fiscal Intermediary Shared Systems (FISS) for the End  Stage Renal Disease (ESRD) Quality Incentive Program (QIP) Adjustments for Childrens Hospitals  04/01/2013 8066 R2588CP 11/05/2012 Implementation of C hanges to the End -Stage Renal Disease (ESRD) Prospective Payment System (PPS) Consolidated Billing 01/07/2013 7869 Rev #  Issue Date  Subject  Impl Date  CR #  Requirements and a Clarification of Outlier Services for Calendar Year 2013  R2504CP  08/02/2012 Implementation of Changes to the End -Stage Renal Disease (ESRD) Prospective Payment System (PPS) Consolidated Billing Requirements and a Clarification of Outlier Services for Calendar Year 2013  Rescinded and replaced by Transmittal 2588 01/07/2013 7869 R2361CP 11/25/2011 Clarification and Revisions for Claims Submitted for End Stage Renal Dise ase (ESRD) Patients  04/02/2012 7593 R2347CP  11/18/2011 Recoupment of Incorrect Payments Made Under the End Stage Renal Disease (ESRD) Prospective Payment System (PPS) for Low-Volume Payment Adjustment  01/03/2012 7626 R2335CP 10/28/2011 Clarification and Revisions for Claims Submitted for End Stage Renal Disease (ESRD) Patients  Rescinded and replaced by Transmittal 2361  04/02/2012 7593 R2311CP 09/23/2011 Implementation of the MIPPA 153c End Stage Renal Disease (ESRD) Quality Incentive Program (QIP) and Other Requirements for ESRD Claims  01/03/2012 7460 R2281CP 08/19/2011 Implementation of Chan ges to the End Stage Renal Disease (ESRD) Prospective Payment System (PPS) Outlier Payment Policy and Changes to the ESRD PPS Consolidated Billing Requirements for Laboratory Services Furnished in a Hospital Emergency Room or Department  01/03/2012 7471 R2269CP 08/05/2011 Clarification of Payment for ESRD -Related Services Under the Monthly Capitation Payment  11/07/2011 7520 R2266CP
(Medicare Claims Processing Manual)
08/05/2011 Clarification of Payment for ESRD -Related Services Under the Monthly Capitation Payment  11/07/2011 7520 R2266CP 07/29/2011 Implementation of Changes to the End Stage Renal Disease (ESRD) Prospective Payment System (PPS) Outlier Payment Policy and Changes to the ESRD PPS 01/03/2012 7471 Rev #  Issue Date  Subject  Impl Date  CR #  Consolidated Billing Requirements for Laboratory Services Furnished in a Hospital Emergency Room or Departme nt  Rescinded and replaced by Transmittal 2281. R2262CP  07/29/2011 Implementation of the MIPPA 153c End Stage Renal Disease (ESRD) Quality Incentive Program (QIP) and Other Requirements for ESRD Claims  Rescinded and replaced by Transmittal 2311 01/03/2012 7460 R2195CP 04/22/2011 End Stage Renal Disease (ESRD) Low Volume Adjustment and Establishing Quarterly Updates to the ESRD Prospective Payment System (PPS)  10/03/2011 7388 R2134CP 01/14/2011 End Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Consolidated Billing for Limited Part B Services  01/03/2011 7064 R2094CP 11/17/2010 End Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Consolidated Billing for Limited Part B Services  Rescinded and replaced by Transmittal 2134  01/03/2011 7064 R2033CP 08/20/2010 End Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Consolidated Billing for Limited Part B Services -  Rescinded and replaced by Transmittal 2094  01/03/2011 7064 R1999CP 07/09/2010 ESRD Home Dialysis MCP  01/03/2011 7003 R1932CP  03/17/2010 Dialysis Adequacy, Infection and Vascular Access Reporting  07/06/2010 6782 R1898CP
(Medicare Claims Processing Manual)
01/29/2010 Dialysis Adequacy, Infection and Vascular Access Reporting - Rescinded and replaced by Transmittal 1932  07/06/2010 6782 Rev #  Issue Date  Subject  Impl Date  CR #  R1655CP  12/31/2008 End Stage Renal Disease (ESRD) Medicare Claims Pro cessing Manual Clarification  02/02/2009 6245 R1648CP  12/12/2008 Implementation of Changes in End Stage Renal Disease (ESRD) Payment for Calendar Year 2009  01/05/2009 6216 R1581CP 08/29/2008 Discarded Erythropoietin Stimulating Agents for Home Dialysis  12/01/2008 6133 R1503CP 05/16/2008 Revisions to the Billing Requirements for ESRD -Related Epoetin Alfa (EPO) and Darbepoetin Alfa (Aranesp) Administration Provided During  Unscheduled or Emergency Dialysis Treatments in the Outpatient Hospital Setting  10/06/2008 6047 R1472CP 03/06/2008 Update of Institutional Claims References  04/07/2008 5893 R1456CP  02/22/2008 Manualization of Payment for Outpatient ESRD -Related Services  03/24/2008 5931 R1421CP 01/25/2008 Update of Institutional Claims References -  Rescinded and Replaced by Transmittal 1472 04/07/2008 5893 R1412CP 01/11/2008 Reporting of Hematocrit or Hemoglobin Levels on All Claims for the Administration of Erythropoiesis Stimulating Agents (ESAs), Implementation of New Modifiers for Non -ESRD Indications, and Reporting of Hematocrit/Hemoglobin Levels on all Non-ESRD, Non -ESA Claims Requesting Payment for Anti- Anemia Drugs  04/07/2008 5699 R1389CP 12/07/2007 Implementation of Change in End Stage Renal Disease (ESRD) Payment for Calendar Year 2008  01/07/2008 5827 R1364CP