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Nephrology

This page supplements the End Stage Renal Disease (ESRD) webpage and provides specific information about Live Donor Services, inclusions and exclusions for MCP billing and CMS resources.

On this page, view the below information.

Live Kidney Donor Services

Expenses for physicians' services rendered to a live kidney donor are treated as though the Medicare beneficiary (recipient) had incurred them. Payment for these services is made at 100 percent of the allowed amount. These services include the donor's pre-operative surgical care, kidney excision inpatient stay and any subsequent related post-operative period. There is no deductible or coinsurance charged for services furnished to live donors.

  • Claims submitted for donor must include below.
    • Recipient name, address and Health Insurance Claim (HIC) number
    • ICD-10 code Z52.4 as a primary diagnosis
    • HCPCS modifier Q3
    • Name and address of live donor
      • Indicate this in documentation record for electronic claims.
      • If a provider meets requirements to submit paper claims, this information must be indicated on a separate attachment to CMS-1500 claim form

Since donor services are submitted under the recipient's Medicare record, it is important that claims are submitted correctly to avoid duplicate denials and claim submission errors.

Monthly Capitation Payment (MCP) Inclusions

Assessment and Diagnosis:

  • Assessment for dietary management
  • Assessment for mode(s) of chronic dialysis best suited for a given patient and recommending appropriate therapy
  • Assessment and determination of type of dialysis access best suited for a given patient
  • Assessment of whether the patient meets preliminary criteria for transplant and presenting findings to patient and family
  • Assessment for intradialytic management; periodic assessment of the patient during dialysis for clinical signs and symptoms and to determine if he or she is tolerating dialysis well
  • Periodic assessment to determine that the patient is receiving the prescribed amount of and adequate dialysis
  • Assessment for significant renal failure-related anemia and determining etiology(ies)
  • Assessment for hyperparathyroidism and/or renal osteodystrophy secondary to chronic renal failure
  • Assessment for dialysis-related arthropathy or neuropathy
  • Assessment for fluid overload
  • Interpretation of: Bone mineral density studies (CPT codes 76070,76075, 78350 and 78351)
  • Non-invasive vascular testing of hemodialysis access (CPT codes 93925, 93926, 93930, 93931 and 93990)
  • Nerve conduction studies (CPT codes 95900, 95903, 95904, 95925, 95926, 95927, 95934, 95935 and 95936)
  • Electromyographic studies (CPT codes 95860, 95861, 95863, 95864, 95867, 95868, 95869 and 95872)
  • Assessment for infection related to treatment and/or immune dysfunction (or intercurrent illness)

Prescribing:

  • Prescribing daily protein, sodium, potassium, fluid and calorie allowances and nutritional supplementation
  • Prescribing intradialytic management parameters including anticoagulant dosage, blood and dialysate flow rates, ultrafiltration rate, type and composition of dialysate, frequency and duration of dialysis, type and frequency of measuring indices of clearance, and intradialytic medications to be administered
  • Prescribing corrective therapy such as oral or parenteral iron and/or erythropoietin
  • Prescribing laboratory and radiographic tests for metabolic bone disease and appropriate therapy such as calcium, phosphate binders and/or vitamin D
  • Prescribing deferoxamine/desferrioxamine chelation therapy
  • Establishing an estimated ideal or 'dry' weight; prescribing fluid removal independent of the dialysis prescription
  • Ordering and reviewing indices of clearance such as urea kinetics; changing the dialysis prescription as appropriate
  • Ordering radiographic, clinical laboratory and other diagnostic studies as appropriate
  • Prescribing treatment, such as antihypertensive medications and their timing relative to dialysis or antibiotic therapy as appropriate

Coordination of Care:

  • Arranging for creation of dialysis access
  • Reviewing treatment with the dialysis nurse or technician
  • Periodic review and update of short-term and long-term care plans with staff; care plan oversight services (HCPCS codes G0181 and G0182) are included in MCP and may not be reported separately
  • Referring the patient to appropriate specialist(s) for evaluation and management of system-specific problems
  • Coordination and direction of patient care by other professional staff, such as dieticians, social workers and clinical psychologists
  • Certification of need for items and services such as durable medical equipment and home health care services

Maintenance Therapy:

  • Periodic physical assessment at intervals based on the patient's clinical stability; periodic review of lab test results
  • Periodic assessment of the patient's dialysis access for adequacy and function
  • Changing the dialysis prescription as appropriate; changing any aspect of the patient's prescription as appropriate
  • Office visits and office/outpatient consultations are included in MCP unless the service is 'significant and separately identifiable' and meets Medicare's requirement for medical necessity (see CPT modifier 25); this applies to services billed under the following CPT codes:
    • 99201-99205 (office visit, new patient)
    • 99211-99215 (office visit, established patient)
    • 99241-99245 (office or other outpatient consultation, new or established): for dates of service prior to January 1, 2010

MCP Exclusions

  • Administration of hepatitis B vaccine
  • Surgical services, such as: Temporary/permanent hemodialysis catheter placement
    • Temporary/permanent peritoneal dialysis catheter placement
    • Repair existing dialysis access
    • Placement of catheter for thrombolytic therapy
    • Thrombolytic therapy
    • Thrombectomy of clotted cannula
    • Arthrocentesis
    • Bone marrow aspiration and biopsy
  • Interpretation of tests that have a professional component, such as:
    • Electrocardiograms (EKGs, or ECGs) 
    • Echocardiograms
    • 24-hour blood pressure monitor
    • Biopsies
    • Spirometry and complete pulmonary function tests (PFTs)
  • Complete evaluation for renal transplant.
    • Assessment of whether patient meets preliminary criteria as transplant candidate is included in MCP, but complete evaluation is excluded from MCP
  • Evaluation of potential living transplant donors
  • Training patients to perform home or self hemodialysis and various forms of self peritoneal dialysis
  • Non-renal related physician's services (may be furnished by physician providing renal care or by another physician). Example: Medical management of diabetes mellitus unrelated to dialysis or furnished during a dialysis session may be submitted separately
  • Covered physician services to hospital inpatients, including services related to inpatient dialysis, by a physician who elects not to continue to receive MCP during period of inpatient stay. Physician receives a prorated MCP for that month
  • All physician services prior to initiation of outpatient dialysis
  • Covered physician services furnished by another physician when patient is not able to receive outpatient services as usual (e.g., when patient is traveling out of town)

Submitting Claims for MCP

Submit a claim at the end of the month with the last date of that month for the 'date of service' for direct patient care services furnished during that month using the appropriate HCPCS code for the patient's age and the number of visits for the month. This includes services that:

  • Are personally furnished by a physician to an individual patient
  • Contribute directly to diagnosis and treatment of an individual patient
  • Ordinarily must be performed by a physician

Other important notes regarding MCPs:

  • Medicare's payment is same regardless of number of days in that month
  • Only one MCP is made for a given month, even if multiple physicians are involved in patient's care
  • If a physician other than MCP physician provides medically necessary services (e.g., test interpretations) that would normally be included or bundled into MCP, Medicare can make separate payment
    • Medicare considers these circumstances to be rare
  • To submit a claim for less than a month of dialysis management for home dialysis patients, use appropriate daily code (CPT codes 90967-90970) with date of each service on a separate line with '1' in units field.
    • These codes are open to outpatient places of service, including:
      • 11-Office
      • 12-Home
      • 22-Outpatient Hospital
      • 31-Skilled Nursing Facility
      • 32-Nursing Facility

Resources

Last Updated Jul 27, 2017

The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.