Description
A Monthly Capitation Payment (MCP) is a payment made to physicians for most dialysis-related physician services furnished to Medicare End Stage Renal Disease (ESRD) patients on a monthly basis. The same monthly amount is paid to the physician for each patient supervised regardless of whether the patient dialyzes at home or as an outpatient in an approved ESRD facility. The claim/claim line with a single paid unit of 90957 or 90960 is the covered service. All additional claim(s)/claim line(s) of 90957-90962, are the overpayments and will be recovered in full.
Affected Code(s)
90957, 90958, 90959, 90960, 90961, 90962
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
4. 42 CFR §405.929- Post-Payment Review
5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. Medicare Claims Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, §140- Monthly Capitation Payment Method for Physicians’ Services Furnished to Patients on Maintenance Dialysis; §140.1- Payment for ESRD-Related Services Under the Monthly Capitation Payment (Center Based Patients); and §140.4- Controlling Claims Paid Under the Monthly Capitation Payment Method
9. AMA CPT Codebook