Guidelines for Physician or Practitioner Billing -- (Per Diem)

140.2.1 - Guidelines for Physician or Practitioner Billing -- (Per Diem) (Rev. 3311, Issued: 08-06-15, Effective: 01-01-15, Implementation: 09-08-15) A. Home dialysis, transient patient and partial month When submitting claims for ESRD-related services (less than full month) per day, the physician or practitioner should specify the number of days he or she was responsible for the beneficiary’s outpatient ESRD-related services during the month. Only one code should be used to report the daily management of home dialysis patients, transient patients, and for partial month scenarios. For example, if a home dialysis patient receives dialysis at home for two weeks and is hospitalized for the remainder of the month, then 14 units of the age appropriate ESRD-related per day code is billed. The MCP service is not billed. For transient patients, the physician or practitioner responsible for the transient patient’s ESRD-related care should bill the appropriate ESRD-related services, per day code. Only the physician or practitioner responsible for the traveling ESRD patient’s care is permitted to bill for ESRD-related services using the per diem ESRD-related services HCPCS codes. For home dialysis patients (less than full month) if the MCP physician or practitioner furnishes a complete monthly assessment of the ESRD beneficiary and at least one face- to-face patient visit during the month, he or she should bill for the age appropriate home dialysis MCP service. For example, if a home dialysis patient was hospitalized during the month and at least one face-to-face outpatient visit and complete monthly assessment was furnished, the MCP physician or practitioner should bill for the full home dialysis MCP service. For partial month scenarios resulting from hospitalization, kidney transplant, or the patient expired, if the MCP physician or practitioner furnished a complete monthly assessment of the patient, he or she should bill using the age appropriate MCP service that reflects the number of visits furnished during the month. Example #1: An ESRD beneficiary was hospitalized on the tenth through the twentieth day of the month. On the third day of the month, the MCP physician or practitioner furnished a face-to-face visit including a complete assessment and a subsequent outpatient visit on the twenty-fifth day of the month. While the patient was hospitalized, an inpatient ESRD-related visit was furnished. In this scenario, the MCP physician or practitioner may bill for the appropriate outpatient MCP service based on the age of the beneficiary and number of visits furnished during the month. The physician or practitioner who furnished the inpatient visit may bill for the appropriate inpatient ESRD-related service code. Example #2: An ESRD beneficiary vacationing in Florida is away from his or her home dialysis site from August fifteenth through September seventh. On August tenth, the MCP physician furnishes a face-to-face visit. For the month of September, the MCP physician furnishes a visit on the ninth and a subsequent visit on the twenty-fifth of the month. A physician in Florida is responsible for the beneficiary’s ESRD-related care from August fifteenth through September seventh. In this scenario, the physician or practitioner responsible for the transient patient’s ESRD-related care bills sixteen units of the age appropriate ESRD-related services for dialysis less than full month, per day code for the month of August and seven units of the per day code for the month of September. The MCP physician bills the MCP service with one visit for the month of August and the MCP service with two to three visits for the month of September. If the transient beneficiary is under the care of a physician or practitioner other than his or her regular MCP physician for an entire calendar month, the physician or practitioner responsible for the transient patient’s ESRD-related care must furnish a complete assessment and bill for ESRD-related services under the MCP. B. Patient has a permanent change in their MCP physician during the month ESRD-related services (less than full month) per day HCPCS codes should be billed in situations where an ESRD beneficiary permanently changes their MCP physician during the month. For example, the new MCP physician has the ongoing responsibility for the evaluation and management of the patient’s ESRD-related care and is not part of the same group practice or an employee of the first MCP physician. The new MCP physician should use the appropriate per diem HCPCS code when submitting claims for ESRD- related services for the remainder of the month, when the first MCP physician furnishes a complete assessment of the beneficiary during the month. If the first MCP physician does not furnish a complete assessment of the patient during the month the patient permanently changes their MCP physician, the new MCP physician may bill for the appropriate MCP service based on the age of the patient and number of visits furnished and the first MCP physician may bill the appropriate per day HCPCS code as discussed above. Example: An ESRD patient residing in Virginia Beach, Virginia for the first 20 days of the month, moves to Atlanta, Georgia. As a result, a different physician or practitioner is now responsible for the ongoing management of the beneficiary’s ESRD-related care. Both the first and second MCP physician furnishes a visit with a complete assessment of the patient and establishes a monthly plan of care. In this situation, the first MCP physician should bill the MCP service that reflects the number of visits he or she furnished during the month and the second MCP physician should bill the age appropriate per day ESRD-related services code. Thereafter, the new MCP physician would bill for the MCP service. In this example, if the first MCP physician does not provide a complete assessment of the patient, he or she should bill 20 units of the per day ESRD-related services code, but may not bill for the MCP during the month the beneficiary permanently changes his or her MCP physician. The second MCP physician may bill for the MCP service after furnishing a complete monthly assessment of the ESRD beneficiary that includes establishing the patient’s plan of care and at least one face-to-face visit.