Benefits and Limitations
This section describes program-specific benefits and
limitations. Refer to Chapter 3, Verifying Recipient Eligibility, for general
benefit information and limitations.
Medicaid covers maintenance dialysis treatments when they
are provided by a Medicaid-enrolled hospital-based renal dialysis center or a
freestanding ESRD facility. The maintenance dialysis treatments do not count
against the routine outpatient visit limit.
Hemodialysis is limited to 156 sessions per year, which
provides three sessions per week.
Continuous Ambulatory Peritoneal Dialysis (CAPD) and
Continuing Cycling Peritoneal Dialysis (CCPD) are furnished on a continuous
basis, not in discrete sessions, and will be paid a daily rate, not on a per
treatment basis.
Providers are to report the number of days in the units
field on the claim. The daily IPD or CAPD/CCPD payment does not depend upon the
number of exchanges of dialysate fluid per day (typically 3-5) or the actual
number of days per week that the patient undergoes dialysis. The daily rate is
based on the equivalency of one week of IPD or CAPD/CCPD to one week of hemodialysis, regardless of the actual number of dialysis
days or exchanges in that week.
Reimbursement will be based on a composite rate consisting
of the following elements of dialysis treatment:
• Overhead costs
• Personnel services, such as administrative services,
registered nurse,
licensed practical nurse, technician, social worker, and
dietician
• Equipment and supplies
• Use of a dialysis machine
• Maintenance of the dialysis machine
• ESRD-related laboratory tests
• Biologicals and certain injectable drugs, such as heparin
and its antidote
NOTE:
Dialysis facilities that have a physician who performs EKGs
on-site can apply to enroll the physician with payment going to the facility.
The CPT-4 procedure codes for EKG tracing and interpretation may be billed
using the physician NPI on the CMS-1500 claim form.
No comments:
Post a Comment