Monday 29 September 2014

End Stage Renal Disease/ Dialysis Services CPT code and revenue code list

Services for the treatment of End Stage Renal Disease (ESRD), including outpatient dialysis services (as defined by, but not limited to, the revenue and CPT codes below), require notification.

No notification is required for end stage renal disease when a Medicare member travels outside of the service area.

Dialysis:

90935, 90937, 4052F, 4054F – hemodialysis
90945, 90947, 4055F – peritoneal
90963 – 90970 – ESRD
90989 – patient training, completed course
90993 – patient training, per session
90999 – unlisted dialysis procedure, inpatient or outpatient

Revenue Codes:

304 – Nonroutine Dialysis
800 – 804, 809 – Renal Dialysis
820 – 825, 829 – Hemo/op or home
830 – 835, 839 – Other outpatient/peritoneal dialysis
840 – 845, 849 – Capd/op or home
850 – 855, 859 – Ccpd/op or home
880 – 882, 889 – Dialysis / misc

For the most current listing of UnitedHealthcare contracted dialysis facilities, please refer to our online provider directory at UnitedHealthcareOnline.com or call us at (877) 842-3210. In an effort to maximize member benefit coverage and lifetime maximum limits, we ask that you refer to UnitedHealthcare contracted dialysis facilities whenever possible. 

Note that your agreement with us may include restrictions on referring members outside the UnitedHealthcare network.

Billing Physician Services - Renal services

Physician Services - Renal services

Physician services rendered to each outpatient maintenance dialysis patient provided during a full month shall be billed on a monthly capitation basis using the appropriate procedure code by age as outlined in the CPT. 

Monthly maintenance dialysis payment (i.e., uninterrupted maintenance dialysis) is comprehensive and covers most of a physician’s services whether a patient dialyzes at home or in an approved ESRD outpatient facility. 

Dialysis procedures are allowed in addition to the monthly maintenance dialysis payment. In general, the Agency follows Medicare guidelines related to monthly capitation payments for physicians. Physician services included in the monthly capitation payment for ESRD related services include, but are not limited to:

• Assessment and determination of the need for outpatient chronic dialysis therapy

• Assessment and determination of the type of dialysis access and dialyzing cycle,

• Management of the dialysis visits including outpatient visits for evaluation and management, management during the dialysis, and telephone calls.

• Assessment and determination if a recipient meets preliminary criteria as a renal transplant candidate including discussions with family members

• Assessment for a specified diet and nutritional supplementation for the control of chronic renal failure, including specifying quantity of total protein, sodium, potassium, amount of fluids, types of anemia and appropriate treatments, type of arthropathy or neuropathy and appropriate treatment or referral, estimated ideal dry weight, etc.

Assessment for diabetic patient’s diet and caloric intake is included also.

• Prescribing the parameters of intradialytic management including anticoagulant, dialysis blood flow rates and temperature, duration and frequency of treatments, etc.

The monthly capitation payment is limited to once per month, per recipient, per provide.

Renal dialysis facility provider type and speciality number

Renal Dialysis Facility

End Stage Renal Disease (ESRD) services are outpatient maintenance services provided by a freestanding ESRD facility or hospital-based renal dialysis center

National Provider Identifier, Type, and Specialty A provider who contracts with Alabama Medicaid as a renal dialysis provider is added to the Medicaid system with the National Provider Identifiers provided at the time application is made. 

Appropriate provider specialty codes are assigned to enable the provider to submit requests and receive reimbursements for dialysis-related claims.

NOTE: The 10-digit NPI is required when filing a claim.

Renal Dialysis Facility providers are assigned a provider type of 30 (Renal Dialysis Facility). The valid specialty for Renal Dialysis Facility providers is Hemodialysis (300).

Enrollment Policy for Renal Dialysis Facility Providers

To participate in Medicaid, End Stage Renal Disease (ESRD) facilities/centers must meet the following requirements:

• Certification for participation in the Title XVIII Medicare Program

• Approval by the appropriate licensing authority

Satellites and sub-units of facilities or centers must be separately approved and contracted with Medicaid .

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