LCD Reference Article Article

Waiver of Face-to-Face Visit for Home Dialysis Patients

A55059

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
NOT AN LCD REFERENCE ARTICLE
This article is not in direct support of an LCD.

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General Information

Source Article ID
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Article ID
A55059
Original ICD-9 Article ID
Not Applicable
Article Title
Waiver of Face-to-Face Visit for Home Dialysis Patients
Article Type
Article
Original Effective Date
07/07/2016
Revision Effective Date
07/07/2016
Revision Ending Date
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Retirement Date
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CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

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Article Guidance

Article Text
Physician management services for patients on dialysis are usually paid for a full month of management services. For in-center dialysis patients, this is billed and paid based on the number of face-to-face visits made during the month and the age bracket of the patient. For home dialysis patients there is a single fee based on the age bracket of the patient. Medicare requires that physicians billing this service must provide certain minimal services including at least one face-to-face visit each month to assess the condition of the vascular access.

Since 2011, CMS has allowed payment of the ESRD Monthly Capitation (MCP) for certain home dialysis patients even when the physician has not actually had a face-to-face visit; this requires an individual waiver at contractor discretion (IOM 100-04, Chapter 8, Section 140.1.1). Starting July 7, 2016, physicians may request this waiver by appending the -52 modifier (reduced services) to the appropriate monthly capitation CPT code (90963 – 90966).

Place the words, “No Face-to-Face” in Item 19 (or electronic equivalent). Noridian may request medical records to assess whether the notes support that the physician actively and adequately managed the care of the home dialysis patient throughout the month. Noridian expects that requests for these waivers will be unusual.


References: Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 140.1.1 at MCPM

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Coding Information

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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.

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Revision History Information

Revision History Date Revision History Number Revision History Explanation
07/07/2016 R1

Updated to indicate this article is not an LCD Reference Article.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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Public Versions
Updated On Effective Dates Status
11/16/2023 07/07/2016 - N/A Currently in Effect You are here
05/13/2016 07/07/2016 - N/A Superseded View

Keywords

  • ESRD
  • Monthly Capitation
  • MCP
  • 90963
  • 90964
  • 90965
  • 90966
  • waiver
  • face to face
  • home visit
  • dialysis