Monthly Capitation Payment Method for Physicians’ Services

140 - Monthly Capitation Payment Method for Physicians’ Services Furnished to Patients on Maintenance Dialysis (Rev. 1456, Issued: 02-22-08, Effective: 03-24-08, Implementation: 03-24-08) Physicians and practitioners managing patients on dialysis (center based) are paid a monthly capitation payment (MCP) for most outpatient dialysis-related physician services furnished to a Medicare end stage renal disease (ESRD) beneficiary. The payment amount varies based on the number of visits provided within each month and the age of the ESRD beneficiary. Physicians and practitioners managing ESRD patients who dialyze at home are paid a single monthly rate based on the age of the ESRD beneficiary, regardless of the number of face-to-face physician or practitioner visits. The MCP is reported once per month for services performed in an outpatient setting that are related to the patients’ ESRD. Physicians and practitioners may receive payment for managing patients on dialysis for less than a full month of care in specific circumstances as discussed in section 140.2. Payment for ESRD related services, less than a full month, is made on a per diem bases. Payment for ESRD-related services is made at 80 percent of the Medicare approved amount (lesser of the actual charge or applicable Medicare fee schedule amount) after the beneficiary’s Part B deductible is met. The beneficiary is responsible for the Part B deductible and the 20 percent coinsurance for physician and practitioner ESRD-related services. A. Services Included in Monthly Capitation Payment The following physician services are included in the MCP: • Assessment of the need for a specified diet and the need for nutritional supplementation for the control of chronic renal failure. Specification of the quantity of total protein, high biologic protein, sodium, potassium, and amount of fluids to be allowed during a given time period. For diabetic patients with chronic renal failure, the prescription usually specifies the number of calories in the diet. • Assessment of which mode(s) of chronic dialysis (types of hemodialysis or peritoneal dialysis) are suitable for a given patient and recommendation of the type(s) of therapy for a given patient. • Assessment and determination of which type of dialysis access is best suited for a given patient and arrangement for creation of dialysis access. • Assessment of whether the patient meets preliminary criteria as a renal transplant candidate and presentation of this assessment to the patient and family. • Prescription of the parameters of intradialytic management. For chronic hemodialysis therapies, this includes the type of dialysis access, the type and amount of anticoagulant to be employed, blood flow rates, dialysate flow rate, ultrafiltration rate, dialysate temperature, type of dialysate (acetate versus bicarbonate) and composition of the electrolytes in the dialysate, size of hemodialyzer (surface area) and composition of the dialyzer membrane (conventional versus high flux), duration and frequency of treatments, the type and frequency of measuring indices of clearance, and intradialytic medications to be administered. For chronic peritoneal dialysis therapies, this includes the type of peritoneal dialysis, the volume of dialysate, concentration of dextrose in the dialysate, electrolyte composition of the dialysate, duration of each exchange, and addition of medication to the dialysate, such as heparin, and the type and frequency of measuring indices of clearance. For diabetics, the quantity of insulin to be added to each exchange is prescribed. • Assessment of whether the patient has significant renal failure-related anemia, determination of the etiology(ies) for the anemia based on diagnostic tests, and prescription of therapy for correction of the anemia, such as vitamins, oral or parenteral iron, and hormonal therapy such as erythropoietin. • Assessment of whether the patient has hyperparathyroidism and/or renal osteodystrophy secondary to chronic renal failure and prescription of appropriate therapy, such as calcium and phosphate binders for control of hyperphosphatemia. Based upon assessment of parahormone levels, serum calcium levels, and evaluation for the presence of metabolic bone disease, the physician determines whether oral or parenteral therapy with vitamin D or its analogs is indicated and prescribes the appropriate therapy. Based upon assessment and diagnosis of bone disease, the physician may prescribe specific chelation therapy with deferoxamine and the use of hemoperfusion for removal of aluminum and the chelation. • Assessment of whether the patient has dialysis-related arthropathy or neuropathy and adjustment of the patient’s prescription accordingly. Referral of the patient for any additional needed specialist evaluation and management of these end- organ problems. • Assessment of whether the patient has fluid overload resulting from renal failure and establishment of an estimated “ideal (dry) weight.” The physician determines the need for fluid removal independent of the dialysis prescription and implements these measures when indicated. • Determination of the need for and prescription of antihypertensive medications and their timing relative to dialysis when the patient is hypertensive in spite of correction of fluid overload. • Periodic review of the dialysis records to ascertain whether the patient is receiving the prescribed amount of dialysis and ordering of indices of clearance, such as urea kinetics, in order to ascertain whether the dialysis prescription is producing adequate dialysis. If the indices of clearance suggest that the prescription requires alteration, the physician orders changes in the hemodialysis prescription, such as blood flow rate, dialyzer surface area, dialysis frequency, and/or dialysis duration (length of treatment). For peritoneal dialysis patients, the physician may order changes in the volume of dialysate, dextrose concentration of the dialysate, and duration of the exchanges. • Periodic visits (at least one per month) to the patient during dialysis to ascertain whether the dialysis is working well and whether the patient is tolerating the procedure well (physiologically and psychologically). During these visits, the physician determines whether alteration in any aspect of a given patient’s prescription is indicated, such as changes in the estimate of the patient’s dry weight. Review of the treatment with the nurse or technician performing the therapy is also included. The frequency of these visits will vary depending upon the patient’s medical status, complicating conditions, and other determinants. • Performance of periodic physical assessments, based upon the patient’s clinical stability, in order to determine the necessity for alterations in various aspects of the patient’s prescription. Similarly, the physician reviews the results of periodic laboratory testing in order to determine the need for alterations in the patient’s prescription, such as changes in the amount and timing of phosphate binders or dose of erythropoietin. • Periodic assessment of the adequacy and function of the patient’s dialysis access appropriate tests and antibiotic therapy. • Interpretations of the following tests: o Bone mineral density studies (CPT codes 76070, 76075, 78350, and 78351); o Noninvasive vascular diagnostic studies of hemodialysis access (CPT codes 93925, 93926, 93930, 93931, and 93990); o Nerve conduction studies (CPT codes 95900, 95903, 95904, 95925, 95926, 95927, 95934, 95935, and 95936); o Electromyography studies (CPT codes 95860, 95861, 95863, 95864, 95867, 95867, 95869, and 95872). • Periodic review and update of the patient’s short-term and long-term care plans with staff. • Coordination and direction of the care of patients by other professional staff, such as dieticians and social workers. • Certification of the need for items and services such as durable medical equipment and home health care services. Care plan oversight services described by CPT code 99375 are included in the MCP and may not be separately reported. B. Services Excluded from Monthly Capitation Payment The following physician services furnished to the physician’s ESRD patients are excluded from the MCP and should be paid in accordance with the physician fee schedule: 1. Administration of hepatitis B vaccine. 2. Surgical services such as: • Temporary or permanent hemodialysis catheter placement; • Temporary or permanent peritoneal dialysis catheter placement; • Repair of existing dialysis accesses; • Placement of catheter(s) for thrombolytic therapy; • Thrombolytic therapy (systemic, regional, or access catheter only; hemodialysis or peritoneal dialysis); • Thrombectomy of clotted cannula; • Arthrocentesis; • Bone marrow aspiration; and • Bone marrow biopsy. 3. Interpretation of tests that have a professional component such as: • Electrocardiograms (12 lead, Holter monitor, stress tests, etc.); • Echocardiograms; • 24-hour blood pressure monitor; • Biopsies; and • Spirometry and complete pulmonary function tests. 4. Complete evaluation for renal transplantation. While the physician assessment of whether the patient meets preliminary criteria as a renal transplant candidate is included under the MCP, the complete evaluation for renal transplantation is excluded from the MCP 5. Evaluation of potential living transplant donors. 6. The training of patients to perform home hemodialysis, self hemodialysis, and the various forms of self peritoneal dialysis. 7. Non-renal related physician’s services. These services may be furnished by the physician providing renal care or by another physician. They may not be incidental to services furnished during a dialysis session or office visit necessitated by the renal condition. The physician must provide documentation that the illness is not related to the renal condition and that the added visits are required. The contractor’s medical staff determines whether additional reimbursement is warranted for treatment of the unrelated illness. For example, the medical management of diabetes mellitus that is not related to the dialysis or furnished during a dialysis session is excluded. 8. Covered physician services furnished to hospital inpatients. 9. All physician services that antedate the initiation of outpatient dialysis. 10. Covered physician services furnished by another physician when the patient is not available to receive the outpatient services as usual; for example, when the patient is traveling out of town.