Renal Dialysis Services
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1 INDIANA HEALTH COVERAGE PROGRAMS PROVIDER REFERENCE M ODULE Renal Dialysis Services L I B R A R Y R E F E R E N C E N U M B E R : P R O M O D P U B L I S H E D : S E P T E M B E R 2 7, P O L I C I E S A N D P R O C E D U R E S A S O F A P R I L 1, V E R S I O N : 1. 1 Copyright 2016 Hewlett Packard Enterprise Development LP
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3 Revision History Version Date Reason for Revisions Completed By 1.0 Policies and procedures as of October 1, 2015 Published: February 25, Policies and procedures as of April 1, 2016 New document Semiannual update: Added a note box for managed care contact information Reorganized information in the Composite Rate for Dialysis section Specified fee-for-service claims in the Billing Guidelines for Renal Dialysis section Clarified and streamlined information in the Dialysis Sessions section and updated the list of applicable revenue codes Added reference to modifier in the billing instructions in the Laboratory Services section Updated descriptions of revenue codes in the Administration of Epoetin section, and removed an end-dated procedure code FSSA and HPE FSSA and HPE Library Reference Number: PROMOD00045 iii
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5 Table of Contents Introduction... 1 Composite Rate for Dialysis... 1 Billing Guidelines for Renal Dialysis... 2 Type-of-Bill Codes... 3 Diagnosis Codes... 3 Revenue Codes... 3 Procedure Codes for ESRD-Related Physician Services... 4 Library Reference Number: PROMOD00045 v
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7 Renal Dialysis Services Note: For policy information regarding coverage of renal dialysis services, see the Medical Policy Manual at indianamedicaid.com. Introduction Patients who have end-stage renal disease (ESRD), a chronic condition with kidney impairment considered irreversible and permanent, require a regular course of dialysis or a kidney transplant to maintain life. The Indiana Health Coverage Programs (IHCP) reimburses for routine dialysis. The cost of dialysis treatments includes overhead costs, personnel services, administrative services (including nursing staff members, social worker, and dietician), equipment and supplies, ESRD-related laboratory tests, certain injectable drugs, and biologicals. This document addresses IHCP coverage, reimbursement, and billing requirements for hemodialysis and peritoneal dialysis services rendered in a hospital outpatient setting, in independent renal dialysis facilities called ESRD dialysis facilities, or in a patient s home. For information on billing transportation services for members on renal dialysis, see the Members on Renal Dialysis or Members Residing in Nursing Homes section of the Transportation Services module. Note: For Healthy Indiana Plan (HIP), Hoosier Care Connect, and Hoosier Healthwise members, providers must contact the appropriate managed care entity (MCE) for specific policies and procedures. MCE contact information is included in the IHCP Quick Reference Guide available at indianamedicaid.com. Composite Rate for Dialysis The composite rate for dialysis is the charge for the actual treatment or dialysis session. The following types of drugs are also included in the composite rate for dialysis: Antiarrhythmics Antihistamines Antihypertensives Dextrose Glucose Heparin and heparin analogs Mannitol Pressor drugs Protamine Saline Library Reference Number: PROMOD
8 Renal Dialysis Services The composite rate also includes all durable and disposable items and medical supplies necessary for the effective performance of a patient s dialysis. Supplies include, but are not limited to, the following: Alcohol wipes Connecting tubes Dialysate Dialysate heaters Forceps Needles Rubber gloves Syringes Topical anesthetics The composite rate covers certain parenteral items used in the dialysis procedure; therefore, these items cannot be billed separately. Routine laboratory charges are included in the fee for hemodialysis or peritoneal dialysis and, as such, are not billed separately. However, the IHCP covers nonroutine lab services when billed separately if medical justification is indicated. See the Laboratory Services section of this document for more information. The following laboratory tests are included in the composite rate: All hematocrit, hemoglobin, and clotting times furnished incident to dialysis treatments Prothrombin time for patients on anticoagulant therapy, serum creatinine, and blood urea nitrogen (BUN) Serum calcium, serum bicarbonate, alkaline phosphatase, serum potassium, serum phosphorous, aspartate aminotransferase (AST, formerly SGOT), serum chloride, total protein, lactate dehydrogenase (LDH), complete blood count (CBC), and serum albumin Note: The facility performing the dialysis treatment must bill all laboratory services performed in conjunction with the dialysis treatment. An independent lab cannot bill labs associated with dialysis for dialysis patients separately. These independent labs should be contracted with the dialysis facility to perform the actual tests and cannot bill the IHCP separately for their services. Billing Guidelines for Renal Dialysis The billing guidelines in this section are for hemodialysis and peritoneal dialysis used in the following settings: Hospital outpatient Independent ESRD dialysis facilities Patient s home Providers of dialysis services must use the UB-04 claim form or 837I electronic transaction to submit claims to the IHCP. The IHCP allows providers to bill for the drugs associated with renal dialysis services on the CMS-1500 claim form or 837P electronic transaction; however; providers must bill all services provided by the ESRD dialysis facility on the UB-04 or 837I. For fee-for service claims, providers must bill each date-specific service separately on the UB-04 claim form. For example, if the patient receives 15 dialysis treatments in the month, enter 15 detail lines of revenue code 821 on the UB-04 claim form, with the specific service date in field 45. This requirement applies for all other services provided during the month. For general billing and claim completion instructions, see the Claim Submission and Processing module. 2 Library Reference Number: PROMOD00045
9 Renal Dialysis Services Type-of-Bill Codes Providers must use the following type-of-bill codes when submitting claims for renal dialysis: Freestanding ESRD dialysis facilities Use type-of-bill code 721. Outpatient hospital renal dialysis facilities Use type-of-bill code 131. Inpatient renal dialysis services Use type-of-bill code 111. Diagnosis Codes See the Renal Dialysis Services Codes on the Code Sets page at indianamedicaid.com for a list of International Classification of Diseases (ICD) diagnosis codes providers must use when submitting claims for renal dialysis. Revenue Codes Providers must use revenue codes on the UB-04 claim form or 837I electronic transaction when billing for renal dialysis. Dialysis Sessions Dialysis sessions are reimbursable at an established flat statewide rate. Providers will only be reimbursed for a single session of dialysis per day. Claims billing more than one of the following revenue codes on the same date of service will be cut back to a single unit of service per day: 820 Hemodialysis Outpatient or home: General 821 Hemodialysis Outpatient or home: Hemodialysis/composite or other rate 830 Peritoneal dialysis Outpatient or home: General 831 Peritoneal dialysis Outpatient or home: Peritoneal dialysis/composite or other rate 840 Continuous ambulatory peritoneal dialysis (CAPD) Outpatient or home: General 841 CAPD Outpatient or home: CAPD/composite or other rate 849 CAPD Outpatient or home: Other 850 Continuous cycling peritoneal dialysis (CCPD) Outpatient or home: General 851 CCPD Outpatient or home: CCPD/composite or other rate 881 Ultrafiltration When billing these revenue codes for a single date of service, providers should indicate a 1 in field 46, Service Units, on the UB-04 claim form. Revenue code 881 is reimbursable only for dates of service on which no other dialysis services were provided. Note: Providers can submit claims for revenue codes 820, 821, 830, 831, 840, 841, 849, 850, 851, and 881 with more than one unit of service on a detail line when multiple units span multiple days. In this case, providers must indicate the date range in the Statement Covers Period field. If providers do not include the date range in this field when billing multiple units of these revenue codes, the claim may be denied. Library Reference Number: PROMOD
10 Renal Dialysis Services Administration of Epoetin Providers must use the following revenue codes with the appropriate Healthcare Common Procedure Coding System (HCPCS) J code when billing for the administration of epoetin alfa in a hospital outpatient or ESRD setting: 634 Erythropoietin (EPO), less than 10,000 units 635 Erythropoietin (EPO), 10,000 or more units The IHCP currently allows payment for HCPCS codes J0885 or Q4081 for patients with a hematocrit range of less than 20 to 40 and above. Drugs Requiring Detailed Coding Revenue code 636 is used with the appropriate HCPCS code to report charges for drugs and biological products that require specific identification when not included in the composite rate. Submit revenue code 636 in field 42 on the UB-04 claim form. Providers must submit the appropriate HCPCS code, including J codes, identifying the specific drug injected, in field 44. In field 46, submit the number of units administered. Supplies The composite rate includes all durable and disposable items and medical supplies necessary for the effective performance of a patient s dialysis (see the Composite Rate for Dialysis section for examples). However, providers can use revenue code 270 to bill for supplies not included in the composite rate. Supplies are not paid if billed in conjunction with treatment room revenue codes. Supply revenue codes are denied if billed without a HCPCS surgical procedure code or if billed in conjunction with treatment room revenue codes 45X, 51X, 52X, 70X, 71X, 72X, and 76X, which are also billed without a HCPCS surgical procedure code. Providers can bill revenue code 270 with multiple units only when the member has one of the renal diagnoses listed in the Renal Dialysis Services Codes on the Code Sets page at indianamedicaid.com and when the service is directly related to the dialysis service. Reimbursement for revenue code 270 is subject to postpayment review and recoupment. Laboratory Services The composite rate for hemodialysis or peritoneal dialysis includes routine laboratory charges (see Composite Rate for Dialysis); therefore, providers cannot bill separately for these charges. However, the IHCP covers nonroutine lab services when billed separately, if medical justification is indicated. Use revenue code category 30X with the appropriate HCPCS code and modifier when billing separately for these charges. Procedure Codes for ESRD-Related Physician Services For ESRD-related physician services, the IHCP uses the same criteria and coding methodology as Medicare. Use procedure codes on the CMS-1500 claim form or 837P electronic transaction to bill for the management of ESRD dialysis services. For descriptions of these codes, see the Renal Dialysis Services Codes on the Code Sets page at indianamedicaid.com. 4 Library Reference Number: PROMOD00045
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