hemodialysis and ESRD benefits and limitation

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

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.

1 comment:

Dale said...

I really like how you described the program-specific benefits and limitations of Hemodialysis and ESRD. Consider these factors if you really need those kinds of treatments.

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