The Jurisdiction F, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 99260-99262 - End Stage Renal Disease. The quarterly edit effectiveness results from October 1, 2019 through December 31, 2019 are as follows:

Top Denial Reasons

• Failure to Return Records
• The information provided does not support the level of service as shown on the claim
• Documentation did not support the credentials of the author

Educational Resources

• ESRD Documentation Requirements
• Medical Documentation Signature Requirements
• CMS Internet Only Manual (IOM), Publication 100-04, Chapter 8
• How to Respond to ADR

Education

Failure To Return Records

The Internet-Only Manual (IOM) addresses timeframes for submission of records for pre-payment reviews in the Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.2.

"When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46."

End Stage Renal Disease (ESRD) (90960-90962)

Physicians and practitioners managing patients on dialysis (center based) are paid a monthly capitation payment (MCP) for most outpatient dialysis-related physician services furnished to a Medicare end stage renal disease (ESRD) beneficiary. The MCP is reported once per month for services performed in an outpatient setting that are related to the patients' ESRD.

The payment amount varies based on the number of visits provided within each month and the age of the ESRD beneficiary. The physician or practitioner who provides the complete assessment, establishes the patient's plan of care, and provides the ongoing management is the physician or practitioner who submits the bill for the monthly service. Visits must be furnished face-to-face by a physician, clinical nurse specialist, nurse practitioner, or physician's assistant. The MCP physician or practitioner may use other physicians or qualified nonphysician practitioners to provide some of the visits during the month. The MCP physician or practitioner does not have to be present when these other physicians or practitioners provide visits.

• 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., do not pay the MCP in advance of the services actually 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, make only one monthly payment for each patient

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 patients ESRD)