Local Coverage Article Billing and Coding

Billing and Coding: Frequency of Hemodialysis

A55354

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Article Information

General Information

Article ID
A55354
Article Title
Billing and Coding: Frequency of Hemodialysis
Article Type
Billing and Coding
Original Effective Date
01/01/2017
Revision Effective Date
01/01/2023
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 11, §10-50, 80, 100, 130 End Stage Renal Disease (ESRD)

CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 8, §10-40.4, 50-60.3, 60.4.2-60.4.7, 60.6, 80.2-90, 90.3.1-90.3.3, 90.5.1-90.5.1.1, 130-140, 160.4-180 Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, all sections including Section 140 Monthly Capitation Payment Method for Physicians’ Services Furnished to Patients on Maintenance Dialysis

CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Transmittal 1084, Change Request 5039, dated October 27, 2006

CMS Manual System, Pub 100-20, One-Time Notification, Transmittal 1849, Change Request 9989, dated May 12, 2017

CMS Final Rule CMS-1651-F published November 4, 2016

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Frequency of Hemodialysis L34575.

The Current Procedural Terminology (CPT®)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

This article outlines how to line item bill dialysis sessions for End Stage Renal Disease (ESRD) patients. This does not address line item billing for sessions associated with training or other modalities such as peritoneal dialysis. This article does not change any other billing requirements for dialysis claims. Note: This article uses the terms dialysis "session" and "treatment" interchangeably.

CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 8, requires line item billing for all ESRD claims with dates of service (DOS) on or after April 1, 2007. Each dialysis session performed should be reported on a separate line.

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 11 discusses that ESRD facilities furnishing dialysis treatments in-facility or in the beneficiary's home are paid for up to 3 treatments per week. Payment for additional treatments, defined as any treatments in excess 3 treatments per week, may be considered in addition to the ESRD PPS per treatment payment amount paid for up to 3 treatments per week.

For monthly claims submitted with Bill Type 72X and Revenue Codes 0821 and 0881, three approaches of billing per line are available. Based on the Patient’s Plan of Care (POC), or other available medical documents, the following scheme should be followed when billing sessions. Note: Dialysis sessions in the patient's POC that are not furnished should not be billed.

  1. For dialysis sessions that have been furnished 3 times (3X) per week, each line should be 90999 without any modifiers appended. That is, when the hemodialysis prescription is 3 times (3X) per week and each session is furnished, all of these sessions should be billed as 90999 (no modifier appended) and they will be paid as routine conventional dialysis up to 13/14 per month.
  2. For each dialysis session furnished in addition to 3 sessions per week that do not include medical documentation supporting a reasonable and necessary determination for payment, each line for these sessions should be billed as 90999 CG. Examples of when this could occur include short, more frequent treatments furnished for the convenience of the patient or staff, etc. Additional sessions need to be billed as 90999 CG when medical documentation has not been submitted to support the extra sessions as reasonable and necessary. The CG modifier indicates that the facility attests the additional treatment is not reasonable and necessary and should not receive additional payment. Each line billed as 90999 CG will be denied. However the use of the modifier is used for data analysis. Please refer to Change Request 9989, Implementation of Modifier CG for Type of Bill 72X, dated May 12, 2017.
  3. For each dialysis session furnished in addition to 3 sessions per week that includes medical documentation supporting a reasonable and necessary determination for payment, each line for these sessions should be billed as 90999 KX. These include medical conditions for acute and occasionally chronic conditions that have supporting documentation that the extra sessions are reasonable and necessary (e.g., through documents from recent hospital care, office visits, dialysis progress notes or MCP visits). These sessions must be reasonable and necessary for additional payment based on clinical conditions. On these claims, the 90999 lines without a modifier will be paid as 3X per week and those lines with 90999 KX will be considered for additional payments. Omission of the KX modifier will result in no additional payment for the line item. For diagnoses not listed in this article but felt to be reasonable and necessary, the KX modifier should be appended as well. A denial will occur on these lines, but the redetermination process (an appeal) will be available to submit supportive documentation for review.

The expectation is that these three scenarios will be seen on monthly claims, i.e., claims with 90999 lines only, or those with lines of 90999 mixed with 90999 CG or KX modifier appended. Ongoing data analysis may trigger provider specific requests for documentation should unusual patterns occur, i.e., claims with only lines of 90999 KX submitted.

Please note that the POC and other supporting medical documentation to justify any of the line item sessions will be most important and may be requested.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT®/HCPCS code must describe the service performed.
  4. The medical record documentation must support the medical necessity of the services as stated in the related policy.

Please see L34575 for instructions when clinical conditions outside those listed in the available diagnoses should occur.

Please see L34575 for additional Documentation Requirements and Utilization Guidelines.

Coding Information

CPT/HCPCS Codes

Group 1

(1 Code)
Group 1 Paragraph

Providers are reminded to refer to the long descriptors of the CPT® codes in their CPT® book.

Group 1 Codes
CodeDescription
90999 UNLISTED DIALYSIS PROCEDURE, INPATIENT OR OUTPATIENT

CPT/HCPCS Modifiers

Group 1

(2 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
CG POLICY CRITERIA APPLIED
KX REQUIREMENTS SPECIFIED IN THE MEDICAL POLICY HAVE BEEN MET

ICD-10-CM Codes that Support Medical Necessity

Group 1

(55 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Medicare is establishing the following limited coverage for CPT® code: 90999 (when reported to represent an extra dialysis session):

Group 1 Codes
CodeDescription
E83.30 Disorder of phosphorus metabolism, unspecified
E83.39 Other disorders of phosphorus metabolism
E87.21 Acute metabolic acidosis
E87.22 Chronic metabolic acidosis
E87.29 Other acidosis
E87.5 Hyperkalemia
E87.70 Fluid overload, unspecified
E87.71 Transfusion associated circulatory overload
E87.79 Other fluid overload
I30.0 Acute nonspecific idiopathic pericarditis
I30.1 Infective pericarditis
I30.8 Other forms of acute pericarditis
I30.9 Acute pericarditis, unspecified
I32 Pericarditis in diseases classified elsewhere
I50.1 Left ventricular failure, unspecified
I50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
I50.30 Unspecified diastolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33 Acute on chronic diastolic (congestive) heart failure
I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.810 Right heart failure, unspecified
I50.811 Acute right heart failure
I50.812 Chronic right heart failure
I50.813 Acute on chronic right heart failure
I50.814 Right heart failure due to left heart failure
I50.82 Biventricular heart failure
I50.83 High output heart failure
I50.84 End stage heart failure
I50.89 Other heart failure
I50.9 Heart failure, unspecified
I77.0 Arteriovenous fistula, acquired
I95.3 Hypotension of hemodialysis
J81.0 Acute pulmonary edema
M32.12 Pericarditis in systemic lupus erythematosus
N25.81 Secondary hyperparathyroidism of renal origin
O09.211 Supervision of pregnancy with history of pre-term labor, first trimester
O09.212 Supervision of pregnancy with history of pre-term labor, second trimester
O09.213 Supervision of pregnancy with history of pre-term labor, third trimester
O09.219 Supervision of pregnancy with history of pre-term labor, unspecified trimester
O09.891 Supervision of other high risk pregnancies, first trimester
O09.892 Supervision of other high risk pregnancies, second trimester
O09.893 Supervision of other high risk pregnancies, third trimester
O09.899 Supervision of other high risk pregnancies, unspecified trimester
R60.1 Generalized edema
R63.5 Abnormal weight gain
T82.898A Other specified complication of vascular prosthetic devices, implants and grafts, initial encounter
T82.898D Other specified complication of vascular prosthetic devices, implants and grafts, subsequent encounter
T82.898S Other specified complication of vascular prosthetic devices, implants and grafts, sequela

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

All those not listed under the ICD-10-CM Codes that Support Medical Necessity section of this article.

Group 1 Codes

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

CodeDescription
072x Clinic - Hospital Based or Independent Renal Dialysis Center

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT®/HCPCS codes included in this article. Providers are reminded that not all CPT®/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT®/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual for further guidance.


CodeDescription
0821 Hemodialysis - Outpatient or Home - Hemodialysis Composite or Other Rate
0881 Miscellaneous Dialysis - Ultrafiltration

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2023 R10

Under CPT/HCPCS Codes Group 1: Codes the description was revised for 90999. This revision is due to the 2023 Annual/Q1 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/23.

10/01/2022 R9

Under ICD-10-CM Codes that Support Medical Necessity Group 1: Codes deleted E87.2 and added E87.21, E87.22, E87.29. This revision is due to the Annual ICD-10-CM Update and will become effective on 10/1/22.

12/10/2020 R8

Under Article Text added Documentation Requirements section and corresponding verbiage and revised verbiage in #4 to read “The medical record documentation must support the medical necessity of the services as stated in the related policy”.

10/01/2019 R7

This article is being revised in response to correspondence from the Alliance for Home Dialysis. The revisions to the article text were made in an effort to more closely align the article language with the LCD language. Revisions are also being done in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of the related Frequency of Hemodialysis L34575 LCD and placed in this article. Under CPT/HCPCS Modifiers added CG and KX modifiers.

07/01/2019 R6

Article revised and published on 07/04/2019 effective for dates of service on and after 07/01/2019. Consistent with CMS Change Request (CR) 10901, the CPT® and ICD-10 codes have been removed from the related LCD and added to the article. In response to an inquiry, language in Article Text item #1 has been modified for clarification regarding the hemodialysis prescription. The article title has been revised.

03/01/2019 R5

This article is being revised nationally for consistency among jurisdictions.

 

 

01/29/2018 R4 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this article begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
08/10/2017 R3

This article was made an A/B MAC. Under Article Title revised the title to Coding for Hemodialysis Sessions. While the information remains the same, verbiage under Article Text was revised for clarification. Under Bill Type Codes added 72X. Under Revenue Codes added 0821 and 0881. Under CPT/HCPCS Codes Group 1: Codes added 90999.

01/01/2017 R2 Under Article Text deleted the second paragraph. Under Article Text in the third paragraph deleted the following verbiage, “…prior to determining the need for more frequent dialysis, or…”
01/01/2017 R1 Under Article Text removed the sentence "For this reason extra treatment sessions are limited to no more than 12 per year."

Associated Documents

Related Local Coverage Documents
LCDs
L34575 - Frequency of Hemodialysis
Related National Coverage Documents
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
01/05/2023 01/01/2023 - N/A Currently in Effect You are here
08/15/2022 10/01/2022 - 12/31/2022 Superseded View
10/20/2020 12/10/2020 - 09/30/2022 Superseded View
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Keywords

  • Frequency of Dialysis
  • Hemodialysis