Refer to the WPS GHA Local Coverage Determination (LCD) L37537, Frequency of Hemodialysis, for reasonable and necessary requirements and frequency limitations.
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 IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 8, requires line item billing for all ESRD claims with dates of service on or after April 1, 2007. Each dialysis session performed should be reported on a separate line.
CMS IOM Publication 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 documentation, the following scheme should be followed when billing sessions. Note: Dialysis sessions in a patient’s POC that are not furnished should not be billed.
- 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.
- For each dialysis sessions furnished in addition to the 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 CR 9989, Implementation of Modifier CG for Type of Bill 72X, dated May 12, 2017.
- 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 services 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 90999CG 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 90999KX submitted.
Please note medical documentation to justify any of these events will be most important and may be requested.
Please see the L37537 for instructions when clinical conditions outside those listed in the available diagnosis should occur.
Please see the L37537 for Documentation Requirements and Utilization Guidelines.