Hemodialysis In-Facility or Home Setting - JE Part A
Hemodialysis In-Facility or Home Setting
End Stage Renal Disease Prospective Payment System (ESRD PPS) payment rate is paid for each hemodialysis treatment in-facility and home at the frequency of three times per week. The maximum treatments are 13 sessions during a 30-day or 14 sessions during a 31-day calendar month. Any medically necessary extra hemodialysis session(s) beyond the monthly maximum must be indicated on the claim form with the use of the CPT 90999 and the KX modifier.
Append the KX modifier on the line item(s) that exceed the maximum in-facility or home dialysis sessions. Noridian reviews the medical justification for additional treatments and is responsible for making the decision on the appropriateness of the extra treatment(s). The documentation in the patient's medical record must support the reason why extra hemodialysis sessions were given beyond the frequency.
Claims that have line items billed with units in excess of the maximum limitation and do not meet medical necessity are rejected.
Resources
- CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 11, Section 50A(1)
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 50.6.2
