Nephrology - JE Part B
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
- Monthly Capitation Payment (MCP) Inclusions
- MCP Exclusions
- Submitting Claims for MCP
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 Medicare ID
- 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, indicate this in Item 19 of 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.
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 patient meets preliminary criteria for transplant and presenting findings to patient and family
- Assessment for intradialytic management; periodic assessment of patient during dialysis for clinical signs and symptoms and to determine if he/she is tolerating dialysis well
- Periodic assessment to determine patient is receiving 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 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 dialysis prescription
- Ordering and reviewing indices of clearance such as urea kinetics; changing 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 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 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
- Periodic physical assessment at intervals based on patient's clinical stability; periodic review of lab test results
- Periodic assessment of patient's dialysis access for adequacy and function
- Changing dialysis prescription as appropriate; changing any aspect of patient's prescription as appropriate
- Office visits and office/outpatient consultations are included in MCP unless service is 'significant and separately identifiable' and meets Medicare's requirement for medical necessity (see CPT modifier 25); this applies to services billed under CPT codes 99201-99205, 99211-99215, and, for dates of service prior to January 1, 2010, 99241-99245.
- 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
- Bone marrow aspiration and biopsy
- Interpretation of tests that have a professional component, such as:
- Electrocardiograms (EKGs, or ECGs)
- 24-hour blood pressure monitor
- 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)
The claim must show the dates of service during the month that are included in the MCP. The claim must include the appropriate HCPCS code for the patient's age and number of visits for the month. The number of Days/Units should be submitted as "1."
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, the billing period includes the first and last days of the full calendar month the MCP physician or practitioner was responsible for the beneficiary's ESRD-related care.
This billing includes services that:
- Are personally furnished by a physician to individual patient
- Contribute directly to diagnosis and treatment of individual patient
- Ordinarily must be performed by a physician
Other important notes regarding MCPs:
- 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).
- 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
- CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 11, End Stage Renal Disease (ESRD)
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims
- CMS Change Request (CR) 5818 - Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions