90999 - Unlisted dialysis procedure, inpatient or outpatient
End Stage Renal Disease (ESRD) occurs from the destruction of normal kidney tissues over a long period of time. Often there are no symptoms until the kidney has lost more than half its function. The loss of kidney function in ESRD is usually irreversible and permanent.
Dialysis is a process by which waste products are removed from the body by diffusion from one fluid compartment to another across a semi-permeable membrane. There are two types of renal dialysis procedures in common clinical usage: hemodialysis and peritoneal dialysis. Both hemodialysis and peritoneal dialysis are acceptable modes of treatment for ESRD under Medicare.
The hemodialysis procedure is a process by which blood passes through an artificial kidney machine and the waste products diffuse across a manmade membrane into a bath solution known as dialysate after which the cleansed blood is returned to the patient’s body. Hemodialysis is accomplished usually in three four hour sessions, three times a week.
Hemodialysis sessions which exceed the frequency of three sessions per week must be medically reasonable and necessary.
Hemodialysis performed or billed more than three times per week may be medically reasonable and necessary for hyperkalemia, pregnancy, fluid overload, acute pericarditis, acute congestive heart failure, acute pulmonary edema or severe catabolic state when these conditions are refractory to dialysis three times per week. Mechanical failure i.e. access impairment, electrical/equipment failure or inadequacy, would also be considered reasonable and medically necessary for an additional hemodialysis session.
The following criteria for indications requiring additional hemodialysis services must be met.
Hyperkalemia – potassium level of 6meq per liter or greater Or a lab evidence of a rapidly rising potassium level Or lab value evidence of significant muscle damage
Volume overload-daily weight gain greater than five pounds per day Or an elevated hemoglobin and hemotocrit Or physical examination with findings indicative of volume overload
Acute pericarditis-physical examination with findings indicative of pericarditis or diagnostic tests which support acute pericarditis (i.e. echocardiogram)
Acute pulmonary edema-physical examination with findings indicative of acute pulmonary edema or laboratory/diagnostic tests which support acute pulmonary edema (i.e. blood gases, echocardiogram, chest x-ray, laboratory tests, CT or nuclear scans)
Hyperkalemia: Elevated potassium may be related to many conditions such as muscle breakdown or to a hypercatabolic state. An extra session may be necessary for people with a potassium level greater than 6 meq per liter or a rapidly rising potassium, or evidence for significant muscle damage such as elevated creatine phosphokinase.
Volume overload: Extra dialysis sessions may be necessary if the patient has evidence of volume overload such as marked daily weight gain in excess of five pounds per day, congestive heart failure, marked edema, pulmonary edema as evidenced by blood gases (hypoxemia), chest X-ray or physical examination, which responds to fluid removal (improves with dialysis) or evidence that volume loads cannot be reduced by other means such as ultrafiltration, and must be removed by dialysis.
A severe catabolic state is a situation in which the creatinine is rising very rapidly and may be associated with hyperkalemia. The creatinine may rise faster than 3–4 mg/dl per day, depending on body mass and other factors. In addition, the muscle enzymes may also be elevated.
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
Dialysis procedure (NOC) used to represent extra dialysis session
• When submitting bills for outpatient ESRD-related visits furnished to patients in hospital observation status, documentation describing the type of ESRD-related services provided during the visit should be included in the medical record.
• Only one claim should be submitted for all ESRD-related services provided during the visit.
• The CPT code 90999 outside of the monthly capitation payment (MCP) should be used to bill for ESRD-related visits furnished to beneficiaries in observational status.
• If the MCP physician furnishes a complete assessment of the patient, the appropriate G code corresponding to the number of visits furnished during the month may be billed.
• The visit furnished in the observational setting must be billed separately from the MCP.
• Examples of billing ESRD-related visits for patients in observation status are included on page 2 of MM3414.
Guidance for Pricing Claims
• The unlisted dialysis procedure code as described by CPT 90999 is carrier-priced.
• When pricing claims for outpatient ESRD-related visits furnished to patients in hospital observation status, the carrier should consider pricing these ESRD-related visits based on the incremental increase between the one visit MCP code and the two to three visit MCP (e.g., the payment difference between G0319 and G0318).
• An example of this pricing scenario is described on page 3 of MM3414. Partial Month Scenarios
• The policy clarifications for partial month scenarios are:
• Physicians and practitioners should use CPT code 90999 when submitting claims for ESRD-related visits furnished in the following partial month scenarios:
• Transient patients – Patients traveling away from home (less than full month);
• Partial month without a complete assessment of the patient; for example, the patient was hospitalized before a complete assessment was furnished, dialysis stopped due to death, or the patient had a transplant; or
• Patients who have a change in their MCP physician during the month.
• For purposes of MM3414, the term “month” means a calendar month. The first month the beneficiary begins dialysis treatments is the date the dialysis treatments begin through the end of the calendar month. Thereafter, the term ‘month’ refers to a calendar month.
Transient Patients and Partial Month without a Complete Assessment of the Patient
• The physician or practitioner should specify the number of days they were responsible for the beneficiary’s outpatient ESRD-related services during the month for transient patients and partial month scenarios, as listed above.
ICD-9-CM Codes That Support Medical Necessity
Transfusion associated circulatory overload
Other fluid overload
Acute pericarditis in diseases classified elsewhere
Congestive heart failure
Left heart failure (pulmonary edema)
Acute edema of lung, unspecified
Unspecified complication of pregnancy, unspecified as to episode of care or not applicable
Other high-risk pregnancy
Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record and be made available to Medicare upon request.
In general, only a fourth session each week will be covered if the service meets the criteria of this policy.