Local Coverage Determination (LCD): Frequency of Dialysis (L35014)

Transcription

1 Lcal Cverage Determinatin (LCD): Frequency f Dialysis (L35014) Cntractr Infrmatin Cntractr Name Nvitas Slutins, Inc. LCD Infrmatin Dcument Infrmatin LCD ID L35014 Original ICD-9 LCD ID L32755 LCD Title Frequency f Dialysis Original Effective Date Fr services perfrmed n r after 10/01/2015 AMA CPT/ADA CDT Cpyright Statement CPT nly cpyright American Medical Assciatin. All Rights Reserved. CPT is a registered trademark f the American Medical Assciatin. Applicable FARS/DFARS Apply t Gvernment Use. Fee schedules, relative value units, cnversin factrs and/r related cmpnents are nt assigned by the AMA, are nt part f CPT, and the AMA is nt recmmending their use. The AMA des nt directly r indirectly practice medicine r dispense medical services. The AMA assumes n liability fr data cntained r nt cntained herein. The Cde n Dental Prcedures and Nmenclature (Cde) is published in Current Dental Terminlgy (CDT). Cpyright American Dental Assciatin. All rights reserved. CDT and CDT-2010 are trademarks f the American Dental Assciatin. Revisin Effective Date Revisin Ending Date Retirement Date Ntice Perid Start Date Ntice Perid End Date

2 CMS Natinal Cverage Plicy This LCD supplements but des nt replace, mdify r supersede existing Medicare applicable Natinal Cverage Determinatins (NCDs) r payment plicy rules and regulatins fr dialysis services. Federal statute and subsequent Medicare regulatins regarding prvisin and payment fr medical services are lengthy. They are nt repeated in this LCD. Neither Medicare payment plicy rules nr this LCD replace, mdify r supersede applicable state statutes regarding medical practice r ther health practice prfessins acts, definitins and/r scpes f practice. All prviders wh reprt services fr Medicare payment must fully understand and fllw all existing laws, regulatins and rules fr Medicare payment fr dialysis services and must prperly submit nly valid claims fr them. Please review and understand them and apply the medical necessity prvisins in the plicy within the cntext f the manual rules. Relevant CMS manual instructins and plicies regarding dialysis services are fund in the fllwing Internet-Only Manuals (IOMs) published n the CMS Web site: Medicare General Infrmatin, Eligibility, and Entitlement Manual Pub , Chapters 1 and 2. Medicare Benefit Plicy Manual Pub , Chapter 11. Medicare Natinal Cverage Determinatins Manual Pub Medicare Claims Prcessing Manual Pub , Chapter 16. Medicare Secndary Payer Manual Pub , Chapter 2. Medicare Financial Management Manual Pub Medicare Prgram Integrity Manual Pub , Chapter 1. Crrect Cding Initiative Medicare Cntractr Beneficiary and Prvider Cmmunicatins Manual Pub , Chapter 5. Scial Security Act (Title XVIII) Standard References, Sectins: 1862(a)(1)(A) Medically Reasnable & Necessary. 1862(a)(1)(D) Investigatinal r Experimental. 1862(a)(6) Persnal Cmfrt Items. 1833(e) Incmplete Claim. Cverage Guidance Cverage Indicatins, Limitatins, and/r Medical Necessity Cmpliance with the prvisins in this plicy may be mnitred and addressed thrugh pst payment data analysis and subsequent medical review audits. Ntice: It is nt apprpriate t bill Medicare fr services that are nt cvered (as described by this entire LCD) as if they are cvered. When billing fr nn-cvered services, use the apprpriate mdifier.

3 Hemdialysis perfrmed r billed mre than three times per week is reasnable and medically necessary fr hyperkalemia, pregnancy, fluid verlad, acute pericarditis, cngestive heart failure, pulmnary edema r severe catablic state when these cnditins are refractry t dialysis three times per week. Hyperkalemia: Elevated ptassium may be related t many cnditins such as muscle breakdwn r t a hypercatablic state. An extra sessin may be necessary fr peple with a ptassium level greater than 6 meq per liter r a rapidly rising ptassium, r evidence fr significant muscle damage such as elevated creatine phsphkinase. Vlume verlad: Extra dialysis sessins may be necessary if the patient has evidence f vlume verlad such as marked daily weight gain in excess f five punds per day, cngestive heart failure, marked edema, pulmnary edema as evidenced by bld gases (hypxemia), chest X-ray r physical examinatin, which respnds t fluid remval (imprves with dialysis) r evidence that vlume lads cannt be reduced by ther means such as ultrafiltratin, and must be remved by dialysis. A severe catablic state is a situatin in which the creatinine is rising very rapidly and may be assciated with hyperkalemia. The creatinine may rise faster than 3 4 mg/dl per day, depending n bdy mass and ther factrs. In additin, the muscle enzymes may als be elevated. Ntice: This LCD impses diagnsis limitatins that supprt diagnsis t prcedure cde autmated denials. Hwever, services perfrmed fr any given diagnsis must meet all f the indicatins and limitatins stated in this plicy, the general requirements fr medical necessity as stated in CMS payment plicy manuals, any and all existing CMS natinal cverage determinatins, and all Medicare payment rules. As published in CMS IOM , , t be cvered under Medicare, a service shall be reasnable and necessary. When apprpriate, cntractrs shall describe the circumstances under which the prpsed LCD fr the service is cnsidered reasnable and necessary under Sectin 1862(a)(1)(A). Cntractrs shall cnsider a service t be reasnable and necessary if the cntractr determines that the service is: Safe and effective. Nt experimental r investigatinal (exceptin: rutine csts f qualifying clinical trial services with dates f service n r after September 19, 2000, that meet the requirements f the clinical trials NCD are cnsidered reasnable and necessary). Apprpriate, including the duratin and frequency that is cnsidered apprpriate fr the service, in terms f whether it is: Furnished in accrdance with accepted standards f medical practice fr the diagnsis r treatment f the patient's

4 cnditin r t imprve the functin f a malfrmed bdy member. Furnished in a setting apprpriate t the patient's medical needs and cnditin. Ordered and furnished by qualified persnnel. One that meets, but des nt exceed, the patient's medical needs. At least as beneficial as an existing and available medically apprpriate alternative. Cding Infrmatin Bill Type Cdes: Cntractrs may specify Bill Types t help prviders identify thse Bill Types typically used t reprt this service. Absence f a Bill Type des nt guarantee that the plicy des nt apply t that Bill Type. Cmplete absence f all Bill Types indicates that cverage is nt influenced by Bill Type and the plicy shuld be assumed t apply equally t all claims. Revenue Cdes: Cntractrs may specify Revenue Cdes t help prviders identify thse Revenue Cdes typically used t reprt this service. In mst instances Revenue Cdes are purely advisry; unless specified in the plicy services reprted under ther Revenue Cdes are equally subject t this cverage determinatin. Cmplete absence f all Revenue Cdes indicates that cverage is nt influenced by Revenue Cde and the plicy shuld be assumed t apply equally t all Revenue Cdes. Nte: The cntractr has identified the Bill Type and Revenue Cdes applicable fr use with the CPT/HCPCS cdes included in this LCD. Prviders are reminded that nt all CPT/HCPCS cdes listed can be billed with all Bill Type and/r Revenue Cdes listed. CPT/HCPCS cdes are required t be billed with specific Bill Type and Revenue Cdes. Prviders are encuraged t refer t the CMS Internet-Only Manual (IOM) Pub , Claims Prcessing Manual, fr further guidance. 082X Hemdialysis - Outpatient r Hme - General Classificatin 083X Peritneal Dialysis - Outpatient r Hme - General Classificatin CPT/HCPCS Cdes

5 Grup 1 Paragraph: Italicized and/r quted material is excerpted frm the American Medical Assciatin, Current Prcedural Terminlgy (CPT) cdes. Nte: Prviders are reminded t refer t the lng descriptrs f the CPT cdes in their CPT bks. Grup 1 Cdes: Dialysis prcedure ICD-10 Cdes that Supprt Medical Necessity Grup 1 Paragraph: It is the prvider s respnsibility t select cdes carried ut t the highest level f specificity and selected frm the ICD-10-CM cde bk apprpriate t the year in which the service is rendered fr the claim(s) submitted. Nte: Prviders shuld cntinue t submit ICD-10-CM diagnsis cdes withut decimals n their claim frms and electrnic claims. The CPT/HCPCS cdes included in this LCD will be subjected t prcedure t diagnsis editing. The fllwing lists include nly thse diagnses fr which the identified CPT/HCPCS prcedures are cvered. If a cvered diagnsis is nt n the claim, the edit will autmatically deny the service as nt medically necessary. Medicare is establishing the fllwing limited cverage fr CPT/HCPCS cde (when reprted t represent an extra dialysis sessin): Cvered fr: Grup 1Cdes ICD-10 Cde Descriptin A18.84 Tuberculsis f heart E87.5 Hyperkalemia E87.70 Fluid verlad, unspecified E87.71 Transfusin assciated circulatry verlad E87.79 Other fluid verlad I32 Pericarditis in diseases classified elsewhere I50.1 Left ventricular failure I50.21 Acute systlic (cngestive) heart failure

6 I50.23 Acute n chrnic systlic (cngestive) heart failure I50.31 Acute diastlic (cngestive) heart failure I50.33 Acute n chrnic diastlic (cngestive) heart failure I50.41 Acute cmbined systlic (cngestive) and diastlic (cngestive) heart failure I50.43 Acute n chrnic cmbined systlic (cngestive) and diastlic (cngestive) heart failure I50.9 Heart failure, unspecified J81.0 Acute pulmnary edema M32.12 Pericarditis in systemic lupus erythematsus O09.70 Supervisin f high risk pregnancy due t scial prblems, unspecified trimester O09.71 Supervisin f high risk pregnancy due t scial prblems, first trimester O09.72 Supervisin f high risk pregnancy due t scial prblems, secnd trimester O09.73 Supervisin f high risk pregnancy due t scial prblems, third trimester O Supervisin f ther high risk pregnancies, first trimester O Supervisin f ther high risk pregnancies, secnd trimester O Supervisin f ther high risk pregnancies, third trimester O Supervisin f ther high risk pregnancies, unspecified trimester O26.90 Pregnancy related cnditins, unspecified, unspecified trimester R60.0 Lcalized edema R60.1 Generalized edema R60.9 Edema, unspecified Shwing 1 t 28 f 28 entries in Grup 1 ICD-10 Cdes that DO NOT Supprt Medical Necessity Additinal ICD-10 Infrmatin General Infrmatin Assciated Infrmatin Dcumentatin Requirements

7 1. All dcumentatin must be maintained in the patient s medical recrd and available t the cntractr upn request. 2. Every page f the recrd must be legible and include apprpriate patient identificatin infrmatin (e.g., cmplete name, dates f service(s)). The dcumentatin must include the legible signature f the physician r nn-physician practitiner respnsible fr and prviding the care t the patient. 3. The submitted medical recrd must supprt the use f the selected ICD-10-CM cde(s). The submitted CPT/HCPCS cde must describe the service perfrmed. 4. The medical recrd dcumentatin must supprt the medical necessity f the services as directed in this plicy. 5. The medical necessity fr additinal dialysis sessins shuld be dcumented in the patient s medical recrd at the dialysis facility and available fr review upn request. The dcumentatin shuld include the physician rders, the physician evaluatin and prgress ntes, the dialysis recrds and results f pertinent labratry tests. Utilizatin Guidelines In accrdance with CMS Ruling 95-1 (V), utilizatin f these services shuld be cnsistent with lcally acceptable standards f practice. The nrmal frequency f hemdialysis is three times per week. Sessins exceeding this frequency must be reasnable and medically necessary. Intermittent peritneal dialysis sessins are billed rutinely at the same frequency as hemdialysis; hwever, the pattern f peritneal dialysis may vary, in which case an equivalence is established between peritneal and hemdialysis. Hemdialysis sessins in excess f this frequency must be reasnable and medically necessary. In general, nly a furth sessin may be cvered in a week if the service meets the criteria f this plicy. Dcumentatin related t these additinal sessins shuld include a valid physician's rder, treatment perfrmed in accrdance with that rder, and apprpriate medical justificatin as utlined in this plicy. Ntice: This LCD impses utilizatin guideline limitatins. Despite Medicare's allwing up t these maximums, each patient s cnditin and respnse t treatment must medically warrant the number f services reprted fr payment. Medicare requires the medical necessity fr each service reprted t be clearly demnstrated in the patient s medical recrd. Medicare expects that patients will nt rutinely require the maximum allwable number f services. Surces f Infrmatin and Basis fr Decisin Fley R N, Gilbertsn D T, Murray T, et al. Lng Interdialytic Interval and Mrtality Amng Patients Receiving Hemdialysis. New England Jurnal f Medicine 2011, 365: In-Center Hemdialysis Six Times Per Week Versus Three Times Per Week. The FHN Trial Grup. The New England Jurnal f Medicine 2010, 363:

8 Kalantar-Zadeh K, Regidr D L, Kvesdy C P, et al. Fluid Retentin is Assciated with Cardivascular Mrtality in Patients Underging Lng Term Hemdialysis. Circulatin 2009, 119: Kumar VA, Ledezma ML, Rasgn, RA. Daily Hme Hemdialysis at a Health Maintenance Organizatin: Three Year experience. Hemdialysis Internatinal : Natinal Kidney Fundatin: KDOQI Guidelines fr CKD Care. (Date Accessed: 8/5/13) Weinhandl E D, Liu J, Gilbertn T D, et el. Survival in Daily Hme Dialysis and Matched Thrice-Weekly In-Center Hemdialysis Patients. J Am Sc Nephrl (5): Other Cntractr Plicies Cntractr Medical Directrs Original JL ICD-9 Surce LCD L34388, Frequency f Dialysis Nvitas Slutins, Inc. JH Lcal Cverage Determinatin (LCD) Cnslidatin, Narrative Justificatin Mst Clinically Apprpriate LCD LCDs Cmpared: L26781, Frequency f Dialysis, TrailBlazer IV, VI, CO, NM, OK, TX - A CMD Ratinale: This is the nly LCD available. It appears well written with clear dcumentatin f the indicatins, limitatin, cding, and utilizatin guidelines. Surces f infrmatin is nt available as TrailBlazer adpted the LCD during a TrailBlazer J4 transitin. L26781 is the mst clinically apprpriate LCD. Revisin Histry Infrmatin Assciated Dcuments Attachments

9 Related Lcal Cverage Dcuments Related Natinal Cverage Dcuments Public Versin(s) Updated n 04/02/2014 with effective dates 10/01/ Keywrds Read the LCD Disclaimer pens in new windw