Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
History/Background and/or General Information
According to the Kidney Disease Outcomes Quality Initiative (KDOQI™) Practice Guideline for Hemodialysis Adequacy: 2015 update1, over 400,000 patients are currently treated with hemodialysis (HD) in the United States, with Medicare spending approaching $90,000 per year of care in 2012. They note mortality rates remain higher than age-matched individuals in the general population. They also experience an average of 2 hospitalizations per year.
The KDOQI™ 2015 Update1 states the following: Attempts to improve outcomes have included initiating dialysis at higher glomerular filtration rates (GFRs), increasing dialysis frequency and/or duration, using newer membranes, and employing supplemental or alternative hemofiltration. Efforts to increase the dose of dialysis administered 3 times weekly have not improved survival, indicating that something else needs to be addressed.
This guideline was also cited in the most recent CMS Final Rule CMS-1651-F published November 4, 2016.
- Metabolic conditions (acidosis, hyperkalemia, hyperphosphatemia)
- Fluid positive status not controlled with routine dialysis
- Heart Failure
- Incomplete dialysis secondary to hypotension or access issues
The following are considered not reasonable and necessary and therefore, will be denied as not medically justified for payments.
- Sessions furnished in excess of 3 sessions per week are not considered reasonable and necessary, unless fully supported in the medical documentation as detailed in this policy
- Planned inadequate or short dialysis
- Sessions performed for convenience of patient or staff
There are documentation requirements in this LCD, which if not followed will generate denials. Please refer to the Documentation Requirements section below.
While there are no set frequency limitations for these services, continued use of additional sessions by a given provider or for a given beneficiary or unusual patterns of billing, verification of need for services may generate reviews. Please refer to the Utilization Guidelines section below.
For coding guidelines, please refer to the related Billing and Coding: Frequency of Hemodialysis A55354 article.
Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy and Billing and Coding: Frequency of Hemodialysis A55354 article; the general requirements for medical necessity as stated in CMS payment policy manuals; any and all existing CMS national coverage determinations; and all Medicare payment rules.
The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.
HD at 3 times (3 X) per week is noted to be ‘conventional’ treatment. Conventional HD remains the most common treatment modality for end stage renal disease (ESRD) worldwide and is usually performed for 3 to 5 hours, 3 days per week. CMS established payment for hemodialysis based on conventional treatment.
Hence, Medicare reimburses HD treatments 3 times per week (13/14 sessions per month depending on length of month). In CMS-1651-F (November 4, 2016), CMS outlines the process for medical justification aspect of the overall requirements of being reasonable and necessary for additional treatment payments.
This LCD sets out medical conditions likely to meet reasonable and necessary requirements for additional payments.
ESRD facilities establish parameters for treatment of any given patient through a Patient Plan of Care (POC). It is defined in the Conditions of Coverage for ESRD Services 42 CFR 494.90. Among other items, the POC developed by the Interdisciplinary Team must provide the necessary care and services to manage the patient’s volume status; and achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7, or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis.
The prescription for chronic hemodialysis therapies includes the type of dialysis access, the type and amount of anticoagulant to be employed, blood flow rates, dialysate flow rate, ultrafiltration rate, dialysate temperature, type of dialysate (acetate versus bicarbonate) and composition of the electrolytes in the dialysate, size of hemodialyzer (surface area) and composition of the dialyzer membrane (conventional versus high flux), duration and frequency of treatments, the type and frequency of measuring indices of clearance, and intradialytic medications to be administered.
Those treatment sessions furnished to the beneficiary are paid by Medicare as 3X per week. If more than 3 sessions per week are furnished, such as 4-6 sessions per week, Medicare will pay the 3X per week amount unless there is a covered indication, appropriate use of the KX modifier occurs, and it is supported by medical documentation. Refer to the related Billing and Coding: Frequency of Hemodialysis A55354 article for more information on appropriate use of the KX modifier.
However, on occasion, acute, and occasionally chronic, conditions may require additional sessions during the month. These may be considered for additional payment. The related Billing and Coding: Frequency of Hemodialysis A55354 article provides a list of diagnoses felt to be consistent with such clinical conditions that could establish reasonable and necessary requirements for payment. Use of these diagnoses should be verified in the medical records to support any payment made.
Clinical conditions not seen listed in this policy may still be appropriate to allow payment. However, these claims may require additional review through the appeals process.
Medicare will monitor the frequency of additional sessions which may trigger Medical Review.
The POC reassessment is noted in 42 CFR 494.80(d).
Please note the POC does not establish medical necessity by itself and will need to be supported by other medical documentation as outlined in the Documentation Requirements below.
Repeated need for additional dialysis sessions is expected to be addressed in the medical documentation and addressed in the subsequent POC, including attempts to correct any issues (see medical Documentation Requirements below).
This LCD establishes Documentation Requirements as listed in the appropriate section below.