Requirements for Payment

160.4 - Requirements for Payment (Rev. 1, 10-01-03) A. General When paying for physicians’ services furnished to dialysis inpatients, whether they are ESRD patients or acute dialysis patients, there are several factors to consider. • The payment must be for covered physicians’ services; • The services must be medically necessary; and • The payment for the services must be reasonably related to the nature of the services actually furnished. B. Physicians’ Services - Criteria for Procedure Codes The procedure code covers the full range of physicians’ renal-related services furnished during an inpatient dialysis treatment. In order to be paid on the basis of a procedure code, the physician must have been physically present with the patient at some time during the course of the dialysis, and the medical record (e.g., the physician’s progress note or the nurse’s notes in the patient’s hospital medical record) must document this. If the physician visits the dialysis inpatient on a dialysis day, but not during the dialysis treatment, do not pay the physician on the basis of a procedure code. The nature of these services is the same as physicians’ services furnished to any inpatient during a hospital visit. Therefore, use the same hospital visit codes that apply to any other physicians treating hospital inpatients. Physicians’ services furnished to patients who are dialyzed as inpatients because there is no room in the outpatient dialysis units are covered under the MCP, and physicians are not paid amounts in addition to or in place of the MCP. Effective January 1, 1995, all evaluation and management services provided on the same day as inpatient dialysis codes should be denied without review with the exception of CPT codes 99221-99223, 99251-99255, and 99238. These codes may be billed with modifier “-25” and reviewed for possible allowance if the evaluation and management service is unrelated to the treatment of ESRD and was not and could not have been furnished during the dialysis treatment. C. Peritoneal Dialysis Peritoneal dialysis is typically furnished in extended periods. For example, CAPD is continuous, and the patient may actually be dialyzed seven days per week. IPD may be furnished in extended periods of 30 hours or more. The fact that a patient is dialyzed continuously for an extended period does not justify payment in excess of the average weekly allowance made for hemodialysis services. Payment in excess of this amount is made only if it is determined that the same kind and intensity of physicians’ hemodialysis treatment beyond the number ordinarily furnished in a 7-day period, and the patient’s condition was similar to that of a hemodialysis patient who would have required these additional services.