Other Services

40 - Other Services (Rev. 13599, Issued: 01-30-26 , Effective: 05-01-26, Implementation: 05-01-26 ) ESRD beneficiaries may receive other services that may be related to their ESRD diagnosis but are excluded from the ESRD PPS payment. Similarly, for AKI beneficiaries, some services related to their diagnosis may be excluded from the AKI dialysis payment. A. Coverage under the Home Health Benefit for ESRD Patients Services that are covered under the ESRD PPS are excluded from coverage under the Medicare home health benefit. Under the home health benefit, services can be provided to dialysis patients as long as the condition that necessitates home health care is not ESRD and as long as home health coverage conditions are met. This is true even where the primary condition relates to kidney failure. For example, Medicare will pay for home health care, such as for decubitus care or for severe hypotension, that is not included in the ESRD PPS. Medicare patients can receive care under both the ESRD benefit and the home health benefit. The key is whether or not the services are being furnished for the treatment of the patient’s ESRD. Surgical dressing changes that are furnished for the treatment of ESRD are to be provided by the ESRD facility, but dressing changes furnished for reasons other than for the treatment of ESRD may be provided under the home health benefit, provided all eligibility criteria have been met. See 42 CFR § 409.49(e). B. Coverage under the Hospice Benefit If the patient’s terminal condition is unrelated to ESRD, the patient may receive covered services under both the ESRD benefit and the hospice benefit. Hospice agencies can provide hospice services to patients who wish to continue dialysis treatment. C. Skilled Nursing Facility (SNF) Patients Needing Dialysis Services Section 4432(b) of the Balanced Budget Act (BBA) requires consolidated billing for SNFs. Dialysis and certain dialysis-related services including covered ambulance transportation to obtain the dialysis services are excluded from SNF consolidated billing, and the services may be billed separately. For more information regarding ESRD patients also receiving services in a SNF, see Pub. 100-02, chapter 8, §10.2 and Pub. 100-04, chapter 6, §20.2.1. D. Nursing Homes and/or Long Term Care Facility (LTC) Patients Needing Dialysis Services Medicare ESRD beneficiaries who reside in a SNF or NF and who meet the home dialysis requirements set forth under 42 CFR §494.100 are considered home dialysis patients. All home dialysis items and services are paid under the ESRD PPS, and no separate payment will be made to the SNF or NF. E. Physician’s Services for ESRD Beneficiaries Physician services are excluded from the ESRD PPS. Payment for physician’s services is subject to the guidelines in Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §30. Medicare pays physician’s services furnished in connection with dialysis sessions for outpatients who are on maintenance dialysis in an ESRD facility or at home by the MCP method or the initial method. For patients who dialyze at home, the ESRD-related services included in the MCP may be provided via telehealth. The MCP physician (or practitioner) must furnish at least one face-to-face patient visit per month for the home dialysis MCP service. See Pub. 100-04, Medicare Claims Processing Manual, Chapter 8 § 140 and Chapter 12 § 190.3.4, for payment instructions. For physician responsibilities, refer to 42 CFR §414.310. F. Renal Dialysis Services Furnished During the Creation or Revision of a Vascular Access The creation or revision of an ESRD patient’s vascular access is usually performed in hospital outpatient departments. Laboratory services, drugs and biological products, and equipment and supplies furnished to ESRD beneficiaries for the treatment of ESRD on the day a procedure is performed to create or revise a vascular access site are not considered to be renal dialysis services. The physicians furnishing renal dialysis services that are subject to the ESRD PPS consolidated billing requirements during the creation or revision of a vascular access for an ESRD beneficiary should bill those services separately with an AY modifier. The appropriate HCPCS or CPT® code indicating the creation or revision of an access site is required on the claim. Items and services that are subject to the ESRD PPS consolidated billing requirements may be found at http://www.cms.gov/ESRDPayment/50_Consolidated_Billing.asp#TopOfPage. G. Noninvasive Vascular Studies for ESRD Patients For dialysis to be performed, there must be a means of access so that the exchange of waste products may occur. As part of the dialysis treatment, ESRD facilities are responsible for monitoring access to determine if the access site is functioning correctly. Procedures associated with monitoring access may include, but are not limited to, taking venous pressure, aspirating thrombus, observing elevated recirculation time, reduced urea reduction ratios, or collapsed shunt, etc. All such procedures are included under the ESRD PPS. Non-invasive vascular studies, such as duplex and Doppler flow scans, are not covered as separately billable services if used to monitor a patient’s vascular access site. If an ESRD facility or a renal physician determines it is reasonable and necessary to monitor the patient’s access site with a non-invasive vascular study (e.g. duplex or Doppler) and does not have the equipment to perform the procedure, the ESRD facility or physician may arrange for the service to be furnished by another source. The alternative source, such as an independent diagnostic testing facility, must look to the ESRD facility for payment. Doppler flow studies may be considered appropriate in the presence of signs or symptoms of possible failure of the ESRD patient’s vascular access site, and when the results are used in determining the clinical course of the treatment for the patient. Routine monitoring is included under the ESRD PPS and includes monitoring by noninvasive Doppler flow studies. Examples supporting the medical necessity for Doppler flow studies include: • Elevated dynamic venous pressure >200mm HG when measured during dialysis with the blood pump set on a 200cc/min., • Access recirculation of 12 percent or greater, • An otherwise unexplained urea reduction ratio <60 percent, and • An access with a palpable “water hammer” pulse on examination, (which implies venous outflow obstruction). Absent documentation supporting the necessity of more than one study, Medicare will limit payment to either a Doppler flow study or an arteriogram (fistulogram, venogram). An example of when both studies may be clinically necessary is when a Doppler flow study demonstrates: • Reduced flow (blood flow rate less than 800cc/min); or • A decreased flow of 25 percent or greater from previous study; and • The physician requires an arteriogram to define the problem. This policy is applicable to claims from ESRD facilities and all other sources, such as independent diagnostic testing facilities and hospital outpatient departments. The professional component of the procedure is included in the MCP. The professional component is denied if billed by the MCP physician. Medically necessary services that are included or bundled into the MCP (e.g., test interpretations) are separately payable when furnished by physicians other than the MCP physician. The MCP physician is identified by the performing provider number that billed MCP services identified by the HCPCS code 90995. Additional information can be found in Pub. 100-04, Medicare Claims Processing Manual, chapter 8 § 180. H. Nutritional Services ESRD facilities are required, in accordance with 42 CFR §494.80(a)(6) and §494.90(a)(2), to evaluate a patients’ nutritional status and expected to assist the patient in achieving their nutritional goals by providing education, counseling, and encouragement. These services are included in the ESRD PPS. Nutritional items, such as nutritional supplements, are not considered related to the treatment of ESRD and are not included in the ESRD PPS as renal dialysis services. Intradialytic Parenteral Nutrition (IDPN) and Intraperitoneal Nutrition (IPN) are not considered renal dialysis services and are therefore not included in the ESRD PPS bundled payment. IDPN and IPN are covered under Medicare Part D. Part B coverage for parenteral nutrition is limited to individuals with a non-functioning digestive tract. When an ESRD facility furnishes a non-ESRD drug, including IDPN or IPN, the staff time is already included in the ESRD PPS payment and, therefore, such costs should not be included in Part D payments. Payment under Part D is limited to the drug ingredients that meet the definition of a Part D drug, subject to the relevant requirements of 42 CFR § 423.120(d), and may include a dispensing fee to cover certain labor costs and pharmacy overhead as permitted under 42 CFR § 423.100. In the case that a pharmacy extemporaneously compounds IPN by adding amino acids to a dialysate, there has been confusion as to whether this falls under Part B or Part D. Dialysate is considered to be a supply related to the renal dialysis treatment, which falls under the ESRD PPS payment and is not separately billable under Part B. Although the dialysate is not separately billable, it is still considered a Part B drug. Therefore, IPN is a Part B compound in accordance with 42 CFR § 423.120(d)(1)(i), and coverage for the entire compound, including ingredients that would independently meet the definition of a Part D drug, would not be available under Medicare Part D. I. Immunizations Immunizations may be separately billed when furnished by an ESRD facility to a Medicare ESRD beneficiary. For further detail, see Pub. 100-04, Medicare Claims Processing Manual, chapter 8, §60.6. J. Blood Products Payment for furnishing blood, blood products, or blood supplies is excluded from the ESRD PPS and will remain separately billable when they are administered in an ESRD facility. For further detail, see Pub. 100-04, chapter 8, §60.3.