Acute Kidney Injury (AKI) Coverage and Billing

Medicare coverage and payment to both hospital-based and freestanding ESRD facilities for renal dialysis services furnished to beneficiaries with AKI began January 1, 2017. ESRD facilities are certified to furnish drugs, biologicals, laboratory services and supplies. Renal dialysis services as defined in 42 CFR §413.171 are considered renal dialysis services for AKI patients. These services given to both pediatric and adult patients with AKI in an ESRD facility are considered related or bundled.

Compensation for Facility Billing

Payment is the amount of the ESRD PPS base rate, as adjusted by the wage index. The base rate includes supplies, drugs and laboratory services in the consolidated billing list. Erythropoietin-stimulating agents (ESAs) are included in the bundled payment billed with the non-ESRD specific HCPCS for treatments administered to patients with AKI. AKI dialysis payment rate is not reduced for ESRD Quality Incentive Program (QIP).

HCPCS Not on Consolidated Billing List and Not Paid Separately

  • J0881
  • J0883
  • J0885
  • J0888
  • Q0138
  • Q5106 (effective January 1, 2019)

Home and Self-Dialysis

AKI is performed in-facility, therefore, dialysis treatments at home or self-dialysis in the dialysis facility are not permitted. These services require supervision by qualified staff during dialysis and close monitoring through laboratory tests. AKI benefits are not extend to home and self-dialysis patients.

Monthly AKI Facility Billing Requirements

  • Type of bill (TOB) 72x
  • Revenue code applicable
    • 082X, 083X or 0881 (ultrafiltration)
  • Condition code 84 (differentiates from ESRD PPS)
  • CPT G0491 (Dialysis procedure at a Medicare certified ESRD facility for AKI without ESRD)
  • One of the following diagnosis codes
    • N17.0 - Acute kidney failure with tubular necrosis
    • N17.1 - Acute kidney failure acute cortical necrosis
    • N17.2 - Acute kidney failure with medullary necrosis
    • N17.8 - Other acute kidney failure
    • N17.9 - Acute kidney failure, unspecified
    • T79.5XXA - Traumatic anuria, initial encounter
    • T79.5XXD - Traumatic anuria, subsequent encounter
    • T79.5XXS - Traumatic anuria, sequela
    • N99.0 - Post-procedural (acute)(chronic) renal failure

There are no billing limits for AKI treatments during a monthly billing cycle; however, reimbursement is made for one treatment per day only.

Not Required for AKI Facility Billing and Reimbursement

  • Value code 48 - Hemoglobin
  • Value code A8 - weight of patient
  • Value code A9 - height of patient
  • Value code D5 - Result of last Kt/V reading
  • Occurrence code 51 - Date of last Kt/V reading
  • Occurrence code urea reduction ratio (URR) modifiers G1 - G6

Physician Billing for AKI

Physicians are able to bill separately for services provided to AKI patients. Physicians are required to follow correct coding guidelines and use the appropriate HCPCS or CPT codes for the items and services provided during treatment of AKI patients.

  • Place of Service (POS)
    • 65 - ESRD Facility
    • 11 - Physician Office
  • CPT Billable Codes - not an all inclusive list
    • 90935
    • 90937
    • 90945
    • 90947

Tips and Additional Information

  • AKI dialysis treatments do count toward the Low Volume Payment Adjustment (LVPA) threshold.
  • Do not submit CPT 90999 on a claim with AKI services and do not append modifier AY on AKI claims.
  • ESRD facilities must perform all items and services necessary to treat patients with AKI.
  • Items and services that are not considered to be renal dialysis services but are a result of AKI are separately payable.
  • Network fee of 50 cents is not applicable
  • Sequestration adjustment is applicable to AKI claims.
  • Telehealth services are not available for AKI patients.
  • Transitional Drug Add-on Payment Adjustment (TDAPA) is not separately payable for AKI patients; do not append AX modifier and HCPCS J0604 or J0606.
    • TDAPA does not apply to AKI claims.
  • Ultrafiltration (revenue code 0881) is used in cases where excess fluid cannot be removed easily during the regular course of hemodialysis. Commonly done during the first hour or two of hemodialysis on patients.

Resources

Last Updated Apr 11 , 2024