Section. 37Renal Dialysis Facility

Section 37Renal Dialysis Facility 37 37.1 Enrollment...................................................... 37-2 37.1.1 STAR and STAR+PLUS Program Enrollment.......................... 37-2 37.2 Reimbursement.................................................. 37-2 37.3 Benefits and Limitations............................................ 37-2 37.3.1 Renal Dialysis............................................... 37-2 37.3.2 Kidney Transplants........................................... 37-2 37.3.3 Facility Services............................................. 37-2 37.3.3.1 Facility Revenue Codes................................... 37-3 37.3.3.2 Maintenance Hemodialysis................................. 37-3 37.3.3.3 Maintenance Intermittent Peritoneal Dialysis (IPD)................ 37-3 37.3.3.4 CAPD and CCPD Support.................................. 37-3 37.3.3.5 Hemodialysis, IPD, CCPD, and CAPD Training................... 37-3 37.3.4 Laboratory and Radiology Services................................ 37-4 37.3.4.1 In-Facility Dialysis Routine Laboratory......................... 37-4 37.3.4.2 Per Dialysis............................................ 37-4 37.3.4.3 Per Week............................................. 37-4 37.3.4.4 Per Month............................................. 37-4 37.3.4.5 In-Facility Dialysis Nonroutine Laboratory...................... 37-4 37.3.4.6 Once a Month.......................................... 37-4 37.3.4.7 Every Three Months...................................... 37-4 37.3.4.8 Every Six Months........................................ 37-4 37.3.4.9 Annually.............................................. 37-4 37.3.4.10 Continuous Ambulatory Peritoneal Dialysis.................... 37-4 37.3.4.11 Every Month.......................................... 37-5 37.3.4.12 Every Three Months..................................... 37-5 37.3.4.13 Every Six Months....................................... 37-5 37.3.4.14 Erythropoietin Alfa (EPO)................................. 37-5 37.3.4.15 Blood Transfusions..................................... 37-6 37.4 Claims Information................................................ 37-6 37.4.1 Claim Filing Resources........................................ 37-6

Section 37 37.1 Enrollment To enroll in the Texas Medicaid Program, a renal dialysis facility must be Medicare-certified in the state that it is located to provide services. Facilities must also adhere to the appropriate rules, licensing, and regulations of the state where they operate. All providers of laboratory services must comply with the rules and regulations of the Clinical Laboratory Improvement Amendments (CLIA) of 1988. Providers who do not comply with CLIA will not be reimbursed for laboratory services. Refer to: Provider Enrollment on page 2-2 for more information. Clinical Laboratory Improvement Amendments (CLIA) on page 25-2. 37.1.1 STAR and STAR+PLUS Program Enrollment Renal dialysis facilities may be eligible to enroll in the State of Texas Access Reform (STAR) and STAR+PLUS Programs as primary care providers (PCP). To be reimbursed for services provided to STAR and STAR+PLUS Program members, Renal dialysis facilities must enroll with each STAR and STAR+PLUS health plan in which their patients are enrolled. 37.2 Reimbursement The Medicaid rates for renal dialysis facilities are composite rates based on calculations specified by the Centers for Medicare & Medicaid Services (CMS). The applicable Medicaid rates are listed in the current 2004 Physician Fee Schedule (PRCR402C.xls), which is available on the TMHP website. Refer to: Reimbursement Methodology on page 3-2 for more information about reimbursement. 37.3 Benefits and Limitations Renal dialysis services are available for Medicaid clients with one of the following diagnoses: Acute renal disease. A renal disease with a relatively short course, usually correctable. Chronic renal disease (CRD) (end stage renal disease). A stage of renal disease that requires continuing dialysis or kidney transplantation to maintain life or health. the original onset date and continues until Medicare coverage begins. If HHSC determines that the client is not eligible for Medicare, Medicaid coverage of eligible clients begins with the original onset date and continues as long as the dialysis treatments are medically necessary and the client is eligible for Medicaid. In the case of a client participating in self-dialysis training before the beginning of the third month, the Medicare waiting period is waived. The waiver is for Medicaid clients who can reasonably be expected to complete the training program and, on completion, enter a self-dialysis setting. 37.3.2 Kidney Transplants Medicare coverage of a client requiring a kidney transplant can begin as early as the month that a patient is hospitalized for transplantation, provided the surgery takes place in that month or in the following two months. Medicare coverage of a client who receives a successful kidney transplant ends with the 36th month after the transplant. At this time, Medicaid resumes full coverage of the client s claims for services covered under the Texas Medicaid Program if the client remains eligible for Texas Medicaid. If HHSC verifies that a Medicaid client is not eligible for Medicare coverage of a transplant, the Texas Medicaid Program pays for the transplantation services. Medicaid does not pay for donor expenses. Facility expenses for kidney procurement, tissue matching, or the cost of maintaining a kidney before transplantation are included in the DRG reimbursement. Medicare benefits for qualified clients include all covered Part A and B items and services. Coverage is not limited to items and services associated with renal disease. Medicaid coverage of Medicare clients extends to Medicare deductible and coinsurance. Medicaid may pay Medicare deductible and coinsurance for clients who are eligible. Refer to: Organ/Tissue Transplants on page 34-96 and Organ/Tissue Transplant Services on page 24-11 for information on organ transplant and facility services. 37.3.3 Facility Services The facility bills an amount that represents the charge for the facility s service to the dialysis patient. The facility s charge must not include the charge for the physician s routine supervision. 37.3.1 Renal Dialysis Medicaid coverage of renal dialysis patients who may have Medicare coverage begins with the original onset date of dialysis treatments and may continue for a period of three months. During this period, TMHP pursues Medicare eligibility through the Texas Health and Human Services Commission (HHSC). If HHSC discovers that the client is Medicare-eligible, Medicaid coverage begins with 37 2

Renal Dialysis Facility 37.3.3.1 Facility Revenue Codes Service Revenue Code Description Maintenance B-821 Hemodialysis (Outpatient/ Home) Composite B-831 Peritoneal Dialysis (Outpatient/Home) Composite B-841 CAPD (Outpatient/Home) Composite B-851 CCPD (Outpatient/Home) Composite Training B-829 Hemodialysis (Outpatient/ Home) Other B-839 Peritoneal Dialysis (Outpatient/Home) Other B-849 CAPD (Outpatient/Home) Other B-859 CCPD (Outpatient/Home) Other Support B-845 CAPD (Outpatient/Home) Support Services B-855 CCPD (Outpatient/Home) Support Services 37.3.3.2 Maintenance Hemodialysis The facility payment applies when a chronic renal disease patient receives hemodialysis in an approved renal dialysis facility. Payment is based on the facility s pertreatment composite rate, as calculated by Medicare. Services included in the facility s charge are routine laboratory tests, personnel services, equipment, supplies, and other services associated with the treatment. For hospitals to be reimbursed for maintenance hemodialysis, they must be enrolled as an approved dialysis facility with the appropriate TPI. 37.3.3.3 Maintenance Intermittent Peritoneal Dialysis (IPD) Maintenance IPD is usually performed in sessions of 10 to 12 hours duration, three times per week. However, it is sometimes performed in fewer sessions of longer duration. If more than three sessions occur in one week, the provider must supply documentation of medical necessity with the claim. 37.3.3.4 CAPD and CCPD Support Support services furnished to maintenance home continuous ambulatory peritoneal dialysis/continuous cycling peritoneal dialysis (CAPD/CCPD) clients will be payable to dialysis facilities. Home dialysis support services must be furnished by the facility in either the home or the facility. Use revenue codes B-845 or B-855 (CAPD and CCPD) when billing such services. CAPD/CCPD support services include, but are not limited to the following: Changing the connecting tube ( administration set ) Watching the patient perform CAPD/CCPD and ensuring that it is done correctly; this observation includes reviewing any aspects of the technique they may have forgotten or informing the patient of modifications in apparatus or technique Documenting whether the patient has or had peritonitis that requires physician intervention or patient hospitalization Inspection of the catheter site Routine laboratory services are not included in the support services and are reimbursed separately. Equipment and supplies are not payable separately. A client with Medicaid coverage may receive CAPD/CCPD support services furnished by the facility at a frequency of once per month. Charges for support services in excess of this frequency must include documentation of medical necessity. 37.3.3.5 Hemodialysis, IPD, CCPD, and CAPD Training Most self-dialysis training is given in an outpatient setting. While CAPD training itself usually does not justify inpatient status, CAPD training is covered when provided to an inpatient. It is reimbursed at the same rate as the facility s outpatient CAPD training rate. Payment for B-829, B-839, or B-859 consists of the facility s composite rate plus $20 per training session. A client who is eligible for Medicaid may receive up to 18 days of training. Additional days of CAPD training (B-849) may be paid only when medical necessity is documented. Payment consists of the facility s composite rate plus $12 per training session. CAPD training services and supplies provided by the dialysis facility include personnel services, parenteral items routinely used in dialysis, training manuals and materials, and routine CAPD laboratory tests. No frequency limitation is applied to routine laboratory tests during the training period because these tests commonly are given during each day of training. Nonroutine laboratory tests performed during the training period require documentation of medical necessity. It may be necessary to supplement the patient s dialysis during CAPD training with intermittent peritoneal dialysis or hemodialysis because the patient has not mastered the CAPD technique. Three supplemental dialysis sessions are covered routinely. If more than three sessions are billed during the training, the claims must document the medical necessity. 37 37 3

Section 37 37.3.4 Laboratory and Radiology Services 37.3.4.1 In-Facility Dialysis Routine Laboratory Laboratory services may be performed in the CRD facility or by an outside laboratory. Charges for routine laboratory tests performed according to the established frequencies in the following tables are included in the facility s dialysis charge billed to Medicaid regardless of where tests were performed. Routine laboratory services performed by an outside laboratory are billed to the facility. 37.3.4.2 Per Dialysis 5-85014 Hematocrit 5-85345, 5-85347 Coagulation time 37.3.4.3 Per Week 5-82565 Assay of creatinine 5-84520 Assay of urea nitrogen 5-85610 Prothrombin time 37.3.4.4 Per Month 5-82040 Assay of serum albumin 5-82310 Assay of calcium 5-82374 Assay, blood carbon dioxide 5-82435 Assay of blood chloride 5-83615 Lactate (LD) (LDH) enzyme 5-84075 Assay alkaline phosphatase 5-84100 Assay of phosphorus 5-84132 Assay of serum potassium 5-84155 Assay of protein, serum 5-84450 Transferase (AST) (SGOT) The routine tests listed in the tables above are frequently performed as an automated battery of tests such as the SMAC-12. These tests are considered routine and are included in the charge for dialysis, unless there is an additional diagnosis to document medical necessity for performing the tests in excess of the recommended frequencies. If it is medically necessary to perform a routine laboratory test beyond the established frequency, payment may be made if the test is indicated on the claim form along with documentation of medical necessity. Refer to: Laboratory Paneling on page 25-5 for more information about laboratory paneling procedures. 37.3.4.5 In-Facility Dialysis Nonroutine Laboratory The following are considered necessary, nonroutine tests. They must be billed separately from the dialysis charge when performed in the CRD facility or by an outside laboratory that bills the facility for laboratory services. All nonroutine laboratory and radiology tests beyond the recommended frequencies require medical justification. Procedure code 1-99001, Specimen handling, for nonroutine laboratory services may be billed to the Texas Medicaid Program only if the specimen is obtained by venipuncture or catheterization and sent to an outside lab. The claim form must document that the handling fee is for nonroutine laboratory services. 37.3.4.6 Once a Month 5-87340 Hepatitis b surface ag, eia 37.3.4.7 Every Three Months T-93005 Electrocardiogram, tracing 37.3.4.8 Every Six Months 4-71010 Chest x-ray 4-71020 Chest x-ray 5-95900 Motor nerve conduction test 37.3.4.9 Annually 4-78300 Bone imaging, limited area 4-78305 Bone imaging, multiple areas 4-78306 Bone imaging, whole body 37.3.4.10 Continuous Ambulatory Peritoneal Dialysis The following laboratory tests are routine for home maintenance CAPD patients when performed according to the indicated frequency. When the patient is dialyzing in the home and is not undergoing intermittent peritoneal dialysis (IPD) or hemodialysis in the facility, payment may be made. The provider must indicate the patient s diagnosis and the type of dialysis on the claim form. Important: Tests in excess of this frequency or tests not listed in the tables, require documentation of medical necessity for payment to be made. 37 4

Renal Dialysis Facility 37.3.4.11 Every Month Laboratory Tests for Routine Home Maintenance CAPD Patients BUN Total protein Creatinine Albumin Sodium Alkaline phosphatase Potassium LDH Carbon dioxide SGOT Calcium Hct Magnesium Hgb Phosphate Dialysate protein 37.3.4.12 Every Three Months Laboratory Tests for Routine Home Maintenance CAPD Patients WBC RBC Platelet count 37.3.4.13 Every Six Months Laboratory Tests for Routine Home Maintenance CAPD Patients Residual renal function Bone mineral density 24-hour urine volume MNCV Chest X-ray EKG 37.3.4.14 Erythropoietin Alfa (EPO) Medicaid reimbursement is allowed for EPO injections administered to chronic renal disease patients, chronic end-stage renal disease predialysis patients who have an anemia with a Hematocrit of 36 percent or less, and for patients with HIV infection who are being treated with Retrovir (AZT). Payment is limited to the end-stage renal dialysis facility and the physician in the office. Only three injections are allowed per seven days. When billing for EPO with a diagnosis of HIV, providers may use diagnosis code 042, HIV. The following diagnoses are payable for EPO: Diagnosis Code Description 042 Human immunodeficiency virus infection 20300 20301 Multiple myeloma 2387 Neoplasm of uncertain behavior, other lymphatic and hematopoietic tissues 2733 Macroglobulinermia (Walden s Macroglobulinemia) 2800 2859 Anemias (refer to the 2004 ICD-9-CM for exact descriptions) Diagnosis Code Description 40300 Hypertensive renal disease malignant, without mention of renal 40301 Hypertensive renal disease malignant, with renal 40310 Hypertensive renal disease benign, without mention of renal 40311 Hypertensive renal disease benign, with renal 40390 Hypertensive renal disease unspecified, without mention of renal 40391 Hypertensive renal disease unspecified, with renal 40402 Hypertensive heart and renal disease malignant, with renal 40403 Hypertensive heart and renal disease malignant, with congestive heart and renal 40412 Hypertensive heart and renal disease benign, with renal 40413 Hypertensive heart and renal disease benign, with congestive heart and renal 40492 Hypertensive heart and renal disease unspecified, with renal 40493 Hypertensive heart and renal disease unspecified, with congestive heart and renal 5820 Chronic, with lesion of proliferative 5821 Chronic, with lesion of membranous 5822 Chronic, with lesion of membranoproliferative 5824 Chronic, with lesion of rapidly progressive 58281 Chronic in diseases classified elsewhere 58289 With other specified pathological lesion in kidney, other 5829 Chronic with unspecified pathological lesion in kidney 37 37 5

Section 37 Diagnosis Code Description 585 Chronic renal (nondialysis) 586 Renal, unspecified (nondialysis) 7140 Rheumatoid arthritis 79001 Precipitous drop in hematocrit 99680 Complications of transplanted organ, unsuspected 99811 Hemorrhage complicating a procedure V420 Kidney transplant status V451 Renal dialysis status V560 Encounter for dialysis, extracorporeal dialysis V5631 Encounter for adequacy testing for hemodialysis V5632 Encounter for adequacy testing for peritoneal dialysis V568 Encounter for dialysis, other dialysis V581 Encounter for chemotherapy The following diagnoses are payable for EPO: Diagnosis Code Description 2733 Macroglobulinemia (Waldenstrom s macroglobulinemia) 99811 Hemorrhage complicating a procedure The procedure codes used when billing for EPO remain unchanged. When billing for EPO, procedure code 1-Q0136, Non esrd epoetin alpha inj, is considered for reimbursement with a covered diagnosis. EPO coverage is limited to three injections per calendar week (Sunday through Saturday). Example: If a client with end-stage renal disease has a hematocrit of 34 percent and is given 5,000 units of EPO, bill a quantity of 5, using code Q4055. The client may receive three payable injections per calendar week (Sunday through Saturday). Important: EPO given for a Hematocrit of 37 percent or above is not a benefit of the Texas Medicaid Program. Use the following procedure codes when billing for blood: Procedure Code Description Maximum Fee O-P9010 Whole blood for $45.00 transfusion O-P9011 Blood split unit $89.37 9-P9021 Red blood cells unit $66.19 Important: Blood administration is considered a professional service and is not payable to dialysis facilities. 37.4 Claims Information Submit all renal dialysis facility services to TMHP in an approved electronic claims format or on a HCFA-1450 (UB92) claim form. Providers must purchase HCFA-1450 claim forms from the vendor of their choice: TMHP does not supply them. Reminder: The original onset date must be included on the claim form to prevent claim denial. The original onset date must be the same date entered on Form 2728 sent to the Social Security office. 37.4.1 Claim Filing Resources Refer to the following sections and/or forms when filing claims: Page Resource Number HCFA-1450 Claim Filing Instructions 4-28 TMHP Electronic Claims Submission 4-11 Communication Guide A-1 Automated Inquiry System (AIS) User s B-1 Guide TMHP EDI General Information C-1 Renal Dialysis Facility CAPD Training F-30 Renal Dialysis Facility CAPD/CCPD F-30 Acronym Dictionary I-1 37.3.4.15 Blood Transfusions Payment of whole blood for transfusions billed by dialysis facilities is a covered service when medically indicated for a client eligible for Medicaid. The administration of blood transfusion is not payable to dialysis facilities and must be billed by the medical professional. 37 6