LCD Reference Article Billing and Coding Article

Billing and Coding: Frequency of Hemodialysis

A56666

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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.

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General Information

Source Article ID
N/A
Article ID
A56666
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Frequency of Hemodialysis
Article Type
Billing and Coding
Original Effective Date
03/01/2019
Revision Effective Date
01/01/2023
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L37564, Frequency of Hemodialysis. Please refer to the LCD for reasonable and necessary requirements.

This article outlines how to line item bill dialysis sessions of 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.

Coding Guidance

Notice
: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

CMS IOM Publication 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 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 three treatments per week. Payment for additional treatments, defined as any treatments in excess of three treatments per week, may be considered in addition to the ESRD PPS per treatment payment amount paid for up to three 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 three times (3X) per week, each line should be 90999 without any modifiers appended. That is, when the hemodialysis-prescription is three 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 the three sessions per week that do not include medical documentation supporting a medically 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 should be billed as 90999 CG when medical documentation has not been submitted to support the extra sessions as medically reasonable and necessary. The CG modifier indicates that the facility attests the additional treatment is not medically 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.
  3. For each dialysis session furnished in addition to three sessions per week that includes medical documentation supporting a medically 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 medically reasonable and necessary (e.g., through documents from recent hospital care, office visits, dialysis progress notes or MCP visits). These sessions must be medically 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 medically 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 these events will be most important and may be requested.

Please see LCD L37564 for instructions when clinical conditions outside those listed in the available diagnosis should occur.

Please see LCD L37564 for Documentation Requirements and Utilization Guidelines.

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Coding Information

Bill Type Codes

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Revenue Codes

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

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ICD-10-CM Codes that Support Medical Necessity

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(55 Codes)
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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. 

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 90999 (when reported to represent an extra dialysis session):

 

 

Group 1 Codes
Code Description
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
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
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All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this article.

Group 1 Codes
Code Description
XX000 Not Applicable
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ICD-10-PCS Codes

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Group 1 Codes

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Additional ICD-10 Information

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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.

Code Description

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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.

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 (IOM) Publication 100-04, Claims Processing Manual, for further guidance.


Code Description

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Other Coding Information

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/01/2023 R3

Article revised and published on 01/26/2023 effective for dates of service on and after 01/01/2023 to reflect the Annual HCPCS/CPT Code Updates. For the following CPT code either the short description and/or the long description was changed. Depending on which description is used in this article, there may not be any change in how the code displays: 90999 in Group 1 Codes.

10/01/2022 R2

Article revised and published on 10/20/2022 effective for dates of service on and after 10/01/2022 to reflect the Annual ICD-10-CM Code Updates. ICD-10-CM code E87.2 has been deleted and therefore has been removed from ICD-10-CM Codes that Support Medical Necessity Group 1. The following ICD-10-CM codes have been added to ICD-10-CM Codes that Support Medical Necessity Group 1: E87.21, E87.22, E87.29. Minor formatting changes have been made throughout the article. 

10/01/2019 R1

Revision Number: 1
Publication: October 2019 Connection
LCR A/B2019-063

Explanation of Revision: This Billing and Coding Article represents the official version of the All Medicare Administrative Contractor (MAC) Workgroup. Some of the verbiage in the article text has been revised for clarification. There will not be a lapse in coverage and there has been no change to the coverage content of this LCD.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L37564 - Frequency of Hemodialysis
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