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PAP 355

Dialysis Billing

Provider Administrative Policy

Claims Submission
Policy Date
February 2012
New/February 2012
Provider Type(s)


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.


Dialysis Billing

Dialysis Claims Billing

For dialysis claims for dates of service on or after 02/15/2011, Blue Cross of Idaho accepts the following CPT Code/Revenue Code combinations for each dialysis modality per diem billed. You must assign the CPT code to the appropriate revenue code indicating the service modality. Submit all claims on a UB-04 form.











 831, 841, 851



 821, 831, 841, 851


Supplies and incidental items are considered included in the maximum allowance for each dialysis modality and are not separately reimbursable, including:

  • Dialysate Solution
  • Disposable catheter tips
  • Drain bag/bottle
  • Surgical masks
  • Supplies and materials (e.g. dressings, gauze, needles, syringes, miscellaneous supplies not otherwise classified)
  • Portable oxygen and nasal cannula
  • Declotting of shunts and any supplies used to declot shunts
  • Staff time to administer blood
  • Y set tubing
  • Cycler dialysis machine (per month)
  • IV administration and injection supply charges

Separately Billable ESRD Drugs
The following drug categories are separately billable by the facility when furnished in hospital-based or independent dialysis facility to treat a patient's renal condition:

  • Anabolics
  • Analgesics
  • Antibiotics
  • Hematinics
  • Muscle relaxants
  • Sedatives
  • Tranquilizers
  • Thrombolytics (used to declot central venous catheters)
  • Vaccines

Blue Cross of Idaho will update the maximum allowances for injectable drugs following notification of any changes or updates on a prospective basis and therefore BCI's updates will generally lag behind CMS. We will not make any payment outside of the dialysis modality allowance for any drugs we consider included in the approved dialysis modality.

Blue Cross of Idaho establishes drug allowances at 150% of the Centers for Medicare & Medicaid Services (CMS) Part B Drug Fee schedule. We will update the maximum allowances for injectable drugs following notification of any changes or updates on a prospective basis and therefore Blue Cross of Idaho's updates will generally lag behind CMS.

Charges billed with CPT or HCPCS codes not addressed on the fee schedule shall default to a zero ($0) payment allowance.

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