Monthly Capitation Payment and the Medical Record - JE Part B

Monthly Capitation Payments for Services Related to End Stage Renal Disease

Physicians and practitioners may be paid an MCP for ESRD-related services provided in outpatient dialysis facilities (center-based). The amount of payment for the MCP is determined under the Medicare physician fee schedule. The payment amount varies based on the age of the enrolled and the number of face-to-face visits that a physician or practitioner provides during each calendar month in which the enrollee receives ESRD-related services. The payment amount also varies based on the geographic location where the ESRD-related services are provided.

Physicians and practitioners bill the MACs using the appropriate CPT codes based on an enrollee’s age and whether ESRD-related services are provided to the enrollee during one visit, two to three visits, or four or more visits in a calendar month. The payment amount is the lowest for one visit, higher for two to three visits, and the highest for four or more visits per month.

The table below shows the three CPT codes that are specific to center-based ESRD enrollees who are 20 years of age and older.

These three CPT codes are to be billed only once per calendar month. The enrollee’s age at the end of the month is the age used to determine the appropriate CPT code. Visits must be furnished face-to-face by a physician or practitioner. At least one of the visits must include a clinical examination of the vascular access site by a physician, a clinical nurse specialist, a nurse practitioner, or a physician’s assistant.

A billing physician or practitioner may use other physicians or practitioners to provide some of the visits during the month. However, the billing physician or practitioner must provide at least one face-to-face visit during the month with the patient. The billing physician or practitioner does not have to be present when other physicians or practitioners provide visits. The other physician or practitioner must be a partner, and employee of the same group practice, or an employee of the billing physician or practitioner. The physician or practitioner who provides the complete assessment, establishes the patient’s plan of care, and provides the ongoing management of the patient should submit the claim for the monthly service.

Payment for ESRD-related services is made at 80 percent of the Medicare-approved MCP amount after an enrollee’s Medicare Part B deductible has been met. The enrollee is responsible for the deductible and 20-percent coinsurance for ESRD related services provided by physicians and practitioners.

Billing Information (CMS-1500 Format)

For the first month the beneficiary begins dialysis treatments, the first date the dialysis treatments begin through the end of the calendar month should be used as the dates of service.

For subsequent (full) months of treatment, submit a date span including the first and last days of the calendar month.

The number of Days/Units should be submitted as "1."

Additional Payment Information

• Only one monthly payment is made for any renal disease patient per month
• The MCP payment is made after the month has passed, i.e., the MCP is not paid in advance of the services furnished
• The payment amount is based on the age of the beneficiary and the number of visits furnished during a calendar month (center-based patients)
• Duplicate charges billed as a duplicate MCP, or as separate charges for services covered by the monthly payment, are denied
• Where several physicians or practitioners form a team to provide the monthly continuity of services to a group of patients, only one monthly payment for each patient is made

Concurrent services by another physician or practitioner who is part of the MCP practice team are covered and reimbursed separately only for services not included in the MCP (e.g., a visit not related to managing the patient’s ESRD).

Medical Record Content

Number of Visits Billed

Enrollees must have the required number of face-to-face visits by a physician or practitioner during the month. The documentation must support that the enrollees had the required number of visits for the billed CPT code.

Clinical Examination of Vascular Access Site

At least one of the required face-to-face visits must include a clinical examination of the vascular access site furnished by a physician or practitioner. The documentation must support that the clinical examinations were provided.

Visits by Billing Physician or Practitioner

The physician or practitioner who submits for the monthly services must be the same physician or practitioner who provided the complete assessment of the enrollee, established the enrollee’s plan of care, and provided at least one of the face-to-face visits during the month. The documentation must support that this occurred.

Resources

CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 8 Sections 140, 140.1, and 140.3