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Nephrology

The following information was initially delveloped by Palmetto GBA as the Jurisdiction 1 Medicare Administrative Contractor and is being published to assist the Jurisdiction E providers served by Noridian. Additional information pertaining to ESRD is available on the Browse by Specialties/ End Stage Renal Disease (ESRD) webpage on this website..

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 the donor must include the following: 
  • Name, address and Health Insurance Claim (HIC) number of the recipient
  • ICD-9 code V59.4 as a primary diagnosis
  • HCPCS modifier Q3
  • Name and address of the live donor Indicate this in the documentation record for electronic claims. If you meet the requirements to submit paper claims, this information must be indicated on a separate attachment to the 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 through 99205 (office visit, new patient)
    • 99211 through 99215 (office visit, established patient)
    • 99241 through 99245 (office or other outpatient consultation, new or established): for dates of service prior to January 1, 2010

Monthly Capitation Payment (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. Note: Assessment of whether the patient meets preliminary criteria as transplant candidate is included in MCP, but the 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 the 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 the 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 the patient is not able to receive the outpatient services as usual (e.g., when the patient is traveling out of town)

Submitting Claims for Monthly Capitation Payment (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 the diagnosis and treatment of an individual patient
  • Ordinarily must be performed by a physician

Other important notes regarding monthly capitation payments (MCPs):

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

References

Last Updated Dec 17, 2015