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MA PAP 242

Renal Dialysis Services Billing


Provider Administrative Policy

Section
Provider Information
Policy Date
October 2011
Status/Date
New/October 2011
Provider Type(s)
N/A  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Renal Dialysis Services Billing

Blue Cross of Idaho requires providers to bill all Medicare Advantage renal dialysis claims following Medicare guidelines as shown below.

Required Coding for claims billed by Dialysis Facilities:

Renal dialysis facilities are required to report hematocrit (HCT) or hemoglobin (HGB) levels for their Medicare patients receiving erythropoietin products (EPO). HCT levels are reported in value code 49 and HGB value code will be denied contractual obligation (CO) requiring the provider to submit a corrected bill to report the value(s).

All claims using CPT code 90999 must be submitted with one of the following most appropriate Urea Reduction Ration (URR) as listed below. If code 90999 is not submitted with one of the modifiers below the claims will be denied for a corrected bill.

G1-Most recent URR of less than 60%

G2-Most recent URR of 60% to 64.9%

G3-Most recent URR of 65% to 69.9%

G4-Most recent URR of 70% to 74.9%

G5-Most recent URR of 75% or greater

G6-ESRD patient to whom less than seven dialysis sessions have been provided.

Reporting the Vascular Access for ESRD Hemodialysis claims. One of the following modifiers is required when revenue code 0821 is billed. It may be reported on one line or all lines. If not reported at all, the claim will be denied for a corrected bill.

Modifier V5-Any vascular catheter

Modifer V6-Arteriovenous Graft

Modifier V7-Arteriovenous Fistula Only

SERVICES PROVIDED WITH SERVICE DATES ON OR AFTER JANUARY 1,2011

Consolidated Billing

The ESRD Prospective Payment System (PPS) will replace the prior basic case-mix adjusted composite payment system and the methodologies for the reimbursement of spearately billable outpatient ESRD related items and services.

The ESRD PPS will provide a single payment to ESRD facilities, i.e., hospital-based providers of service and renal dialysis facilities that will cover all the resources used in providing an outpatient dialysis treatment, including drugs, biological, laboratory tests, training, support services, supplies and equipment used to administer dialysis in the ESRD facility or at patient's home.

  1. Consolidated billing requirements only apply to members within the parameters of the Dialysis Phase.
  2. Claims will be denied for a corrected bill if the claim dates of service span a year change (i.e., 2011 and 2012).
  3. Any line submitted with revenue code 0880 will be denied for a corrected bill, indicating the provider is required to bill to the highest level of specificity.
  4. Telehealth services billed with HCPCS Q3014, preventive services covered by Medicare, and blood and blood services are exempt from teh ESRD PPS and will be paid based on existing payment methodologies.
  5. Payment for ESRD-related Aranesp and ESRD-related Epoetin Alfa (EPO) are included in the ESRD PPS for claims with dates of service on or after January 1,2011.
  6. Oral and other equivalent forms of injectable drugs should be reported with revenue code 0250. The NDC number must be submitted on the claim. If not billed correctly, the claim will be denied for a corrected bill.
  7. All services billed by the ESRD facility are reimbursed through the ESRD PPS Pricer at the "bundled" allowance unless billed with an AY modifier.
  8. Services provided, but not related to the treatment of ESRD, should be submitted with the AY modifier. Separate payment outside of the ESRD PPS will be mad for these services. All 72X claims from Method II facilities with condition code 74 will be treated as Method I as of January 1, 2011. Medicare will no longer differentiate Method selections.

Claims Submitted by Providers other than a Renal Dialysis Facility

Certain laboratory services, limited drugs, and supplies will be subject to consolidated billing and will no longer be separately payable when provided for ESRD beneficiaries by providers other than the renal dialysis facility. Claims subject to consolidated billing include:

  • a primary diagnosis code of 585.6, ESRD AND
  • the claim contains any of the services listed in the tables below, AND
  • there is no AY modifier on the services, the services will be denied.

EXCEPTION-Services listed in the tables below that are billed with an AY modifier are reimbursable unless otherwise noted.

DME ESRD SUPPLY HCPCS for ESRD PPS:

The following HCPCS will be subject to consolidated billing and will no longer be separately payable unless the service is billed with the AY modifier. The HCPCS considered consolidated billing are listed in the table below.

 A4215 A4244 A4247A4452  A4663A4928 A6215  A6402
 A4216 A4245 A4248 A4657 A4670 A4930 A6250 E0210
 A4218 A4246 A4450 A4660 A4927 A4931 A6260 E1639

 

DME ESRD SUPPLY HCPCS NOT PAYABLE TO DME SUPPLIERS:

The following HCPCS are considered non-covered and if submitted will be subject to consolidated billing and will no longer be separately payable. The HCPCS considered consolidated billing are listed in the table below.

EXCEPTION:  HCPCS code A4913 is separately reimbursable if billed with AY modifier.

 A4651 A4709 A4736A4774 E1530 E1615 
 A4652 A4714 A4737 A4802 E1540 E1620
 A4653 A4719 A4740 A4860E1550  E1625
 A4671 A4720 A4750 A4870 E1560 E1630
 A4672 A4721 A4755 A4890 E1570 E1632
 A4673 A4722 A4760 A4911 E1575 E1634
 A4674 A4723 A4765 A4913 E1580 E1635
 A4680 A4724 A4766 A4918 E1590 E1636
 A4690 A4725 A4770A4929  E1592 E1637
 A4706 A4726 A4771 E1500 E1594 E1699
 A4707 A4728 A4772 E1510 E1600 
 A4708 A4730 A4773 E1520 E1610 

 

LABS SUBJECT TO ESRD CONSOLIDATED BILLING:

The following HCPCS will be subject to consolidated billing and will no longer be separately payable unless the service is billed with the AY modifier. The HCPCS considered consolidated billing are listed in the table below.

82040825658354084155  8502586705 87077
 82108 82570 83550 84295 85027 86706 87081
 82306 82575 83735 84466 85041 87040 87340
 8231082607 83970 84520 85044 87070 G0306
 82330 82652 84075 845408504587071

 G0307

82374 82668 84100 84545 85046 87073 
8237982728 84132 85014 85048 87075 
 82435 82746 84134 85018 86704 87076 

DRUGS SUBJECT TO ESRD CONSOLIDATED BILLING:

The following HCPCS will be subject to consolidated billing and will no longer be separately payable unless the service is billed with the AY modifier. The HCPCS considered consolidated billing are listed in the table below.

J0610J0636J0895J1645 J1945 J2460 J2997J3365 
J0630 J0878 J1270 J1740 J1955 J2501 J3360 J3420
J0635J0882 J1642J1756  J2250 J2916 J3364 Q4081
 J1644 J2993      

SERVICES PROVIDED WITH SERVICE DATES PRIOR TO JANUARY 1,2011

Required Coding for claims billed by Dialysis Facilities:

Renal dialysis facilities are required to report hematocrit or hemoglobin levels for their Medicare patients receiving erythropoietin products (EPO). Hematocrit levels are reported in value code 49 and Hemoglobin readings are reported in value code 48. EPO services submitted without either HCT or HGB value code will be denied contractual obligation (CO) for a corrected bill.

NOTE:  CMS quality of care modifiers do not impact benefits and therefore are not required.

Separately Billable ESRD Items and Services:

Lab Services-Refer to the Medicare Benefit Policy Manual, Chapter 11, for a description of lab services included in the composite rate. For lab services not included in the composite rate, the Medicare laboratory fee schedule for independent laboratories is used to price the lab service.

Drugs-There are some drugs that are not covered under the composite rate, but that may be medically necessary. Refer to the Medicare Benefit Policy Manual Chapter 11 for a description of drugs that are part of the composite rated and drugs that are considered separately billable. Appropriate HCPCS codes for administration-supply of separately billable drugs would include: A4657. Injection Administration-supply charge: include the cost of alcohol swab, syringe, and gloves.

There are some drugs that are not covered under the composite rate, but that may be medically necessary for some patients receiving dialysis. See Medicare Benefit Policy Manual Chapter 11. According to Medicare Claims processing Manual Chapter 8, separately billable ESRD drugs include but are not limited to the following when used to treat the patient's renal condition:

  • Antibiotics;
  • Analgesics;
  • Anabolics;
  • Hematinics;
  • Muscle Relaxants;
  • Sedatives;
  • Tranquilizers; and
  • Thrombolytics: used to declot central venous catheters.

NOTE:  Services considered not separately billable or part of the composite rate will be paid at zero dollars.

Out-of-Area: Medicare Advantage plans are required to make timely and reasonable payment to non-contracting providers for renal dialysis services provided when a plan enrollee is temporarily outside the plan's service area. The Medicare Advantage plan cannot require prior authorization or advance notification for dialysis services as a condition of coverage when an enrollee is temporarily absent from the plan's service area. Claims received for dialysis services from a non-contracting out of area provider will not require an authorization and will be reimbursed based upon the fee schedule from the state in which services were rendered for all ancillary services.

Non-Contracting Provider:

Claims received for dialysis supplies and services from non-contracting in-state providers will not require a prior authorization. All ancillary services not reimbursed according to the composite rate reimbursement, should be reimbursed based upon the Idaho fee schedule.

Contracting Physicians:

Dialysis supplies and services from contracting physician do not require preauthorization.

NOTE:  Many ancillary supply services are carrier discretion and are not separately reimbursable. claims for ancillary services may be routed to the Medical Management unit for medical necessity review.

Resources: Medicare claims Processing Manual, Chapter 8 and Medicare Benefit Policy Manual, Chapter 11.

 


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