CPT code 90999 - Frequency of Dialysis - covered DX 276.61 , V23.89

procedure code and description


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)

Hemodialysis and peritoneal dialysis performed or billed more than three times per week is reasonable and medically necessary for hyperkalemia, pregnancy, fluid overload, acute pericarditis, congestive heart failure, pulmonary edema or severe catabolic state when these conditions are refractory to dialysis three times per week.

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.

 Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • 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.


HCPCS Codes
Note:
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.
90999©
Dialysis procedure (NOC) used to represent extra dialysis session
Billing and Coding Update on EHRD

This MLN Matters® Article is intended for End- Stage Renal Disease (ESRD) facilities that  submit claims to Medicare Administrative Contractors (MACs) for ESRD services provided   to Medicare beneficiaries change Request (CR) 9609 implements condition code 87 that can be used on the 72X type  of bill for ESRD facilities to indicate that the ESRD beneficiary is receiving a retraining  treatment  CR9609 also introduces the UJ modifier to show the provision of nocturnal  hemodialysis. Make sure your billing staffs are aware of these changes.

Effective January 1, 2011, The Centers for Medicare & Medicaid Services (CMS)  implemented the  ESRD Prospective Payment System (PPS) based on the requirements of  Section 1881(b)(14) of the Social Security Act (the Act) as amended by Section 153(b) of the  Medicare Improvements for Patients and Providers Act (MIPPA). The ESRD PPS provides a  single per-
treatment payment to ESRD facilities that covers all of the resources used in  furnishing an outpatient dialysis treatment.
The ESRD PPS provides a home and self- dialysis training add -on payment adjustment when  the beneficiary is training for home or self -dialysis. The training add-on payment adjustment is applied to a maximum  of 25 treatments for hemodialysis and 15 treatments for peritoneal  dialysis. After the initial training is completed, ESRD facilities can receive the training add -on  payment adjustment when ESRD beneficiaries are retraining. Currently, ESRD facilities  report the 73 condition code for both training and retraining. 

Nocturnal Hemodialysis - Effective January 1, 2017

Nocturnal hemodialysis is performed either at home or in a dialysis facility while the patient is  sleeping. It is a longer and slower form of hemodialysis that can be >5 hours per treatment, 3  to 7 days a week.  

Currently under the ESRD PPS, there is no claims processing mechanism for ESRD facilities  to recognize that an  ESRD beneficiary is receiving nocturnal hemodialysis. CR9609  implements the UJ modifier – services provided at night, for ESRD facilities to append on the  dialysis line to indicate that the treatment furnished is nocturnal hemodialysis, that is, longer  and slower hemodialysis that can be performed at home or in- facility for >5 hours per  treatment, 3 -7 days a week. 


Home and Self -Dialysis Training Add -on Payment Adjustment - Effective April 1, 2017

There are no changes to the home and self -dialysis training  policy discussed in the “Medicare  Benefit Policy Manual,”
 Chapter 11, Section 30.2. CR9609 does implement a treatment cap  for the number of training treatments furnished to ESRD beneficiaries. ESRD beneficiaries  that receive training for hemodialysis should not receive more than 25 training  reatments. 

ESRD beneficiaries that receive training for continuous cycling peritoneal dialysis and  continuous ambulatory peritoneal dialysis should not receive more than 15 training  treatments.


Home and Self -Dialysis Retraining 

- Effective July 1, 2017
There are no changes to the home and self -dialysis retraining policy discussed in  the  “Medicare Benefit Policy Manual,” Chapter 11, Section 30.2.E. CR9069 does implement  condition code 87 (ESRD Self Care Retraining)  that  can be used on the 72X type of bill for  ESRD facilities to indicate that the ESRD beneficiary is receiving a retraining treatment

Guidelines for Physician or Practitioner Billing and Documentation

• 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
The CPT/HCPCS codes included in this LCD will be subjected to procedure to diagnosis editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS code 90999 (when used to represent extra dialysis session):

Covered for:
276.61
Transfusion associated circulatory overload
276.69
Other fluid overload
276.7
Hyperpotassemia
420.0
Acute pericarditis in diseases classified elsewhere
428.0
Congestive heart failure
428.1
Left heart failure (pulmonary edema)
518.4
Acute edema of lung, unspecified
646.90
Unspecified complication of pregnancy, unspecified as to episode of care or not applicable
782.3
Edema
V23.89
Other high-risk pregnancy
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Documentation Requirements
The medical necessity for additional dialysis sessions should be documented in the patient’s medical record at the dialysis facility and available for review upon request. The documentation should include the physician orders, the physician evaluation and progress notes, the dialysis records and results of pertinent laboratory tests.

Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record and be made available to Medicare upon request.

Utilization Guidelines
The normal frequency of hemodialysis is three times per week. Sessions exceeding this frequency must be reasonable and medically necessary. Intermittent peritoneal dialysis sessions are billed routinely at the same frequency as hemodialysis; however, the pattern of peritoneal dialysis may vary, in which case an equivalence is established between peritoneal and hemodialysis. Hemodialysis sessions in excess of this frequency must be reasonable and medically necessary.

In general, only a fourth session each week will be covered if the service meets the criteria of this policy.
Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.

1 comment:

Monserrat Smith said...

Hey you are right pulmonary edema is reason of heart failure.Pulmonary edema is an abnormal buildup of fluid in the air sacs of the lungs, which leads to shortness of breath.
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