Billing Physician Dialysis Services (codes 90935 - 90999) and

170 - Billing Physician Dialysis Services (codes 90935 - 90999) and Related Payment (Rev. 1, 10-01-03) Except when the MCP applies claims for physicians’ inpatient dialysis services furnished to ESRD or acute dialysis patients are processed using physicians’ inpatient dialysis services procedure codes 90935, 90937, 90945, and 90947. All A/B MACs (B) must use these codes for these services. A/B MACs (B) make payment on the basis of ESRD procedure codes, i.e., codes 90935, 90937, 90945, or 90947, only if the place of service on the claim is inpatient hospital. This is because all physicians’ outpatient renal-related services are included in payment made under the monthly capitation payment. A. ESRD Monthly Capitation Payments Effective January 1, 1995, monthly capitation payments are made under the physician fee schedule. For their adult patients, physicians may bill either the monthly code (CPT code 90921) or the daily code (CPT code 90922) with units that represent the number of days in a single month, but may not bill both. To bill for a month of services for pediatric patients, providers should bill the appropriate monthly code (CPT codes 90919, 90920, or 90921). To bill for less than a month of service, providers bill the appropriate daily code (CPT codes 90923-90925) and units that represent the number of days. Providers may bill either the monthly code or the daily code, but not both. Since billing is done at the conclusion of the month, the patient’s age at the end of month is the age of the patient for billing purposes. B - Inpatient and Outpatient Dialysis Services On Same Date As An Evaluation and Management Service CPT codes 90935 and 90937 are used to report inpatient ESRD hemodialysis and outpatient hemodialysis performed on non-ESRD patients (e.g., patients in acute renal failure requiring a brief period of dialysis prior to recovery). CPT codes 90945 and 90947 are used to report all non-hemodialysis procedures. All four of these codes include payment for any evaluation and management services related to the patients renal disease that are provided on the same date as the dialysis service. Therefore, payment for all evaluation and management services is bundled into the payment for 90935, 90937, 90945, and 90947, except for the following evaluation and management services which may be reported on the same date as a dialysis service with the use of the –25 modifier and they are significant and separately identifiable and met any medical necessity requirements: 99201-99205 Office or Other Outpatient Visit for a New Patient 99211-99215 Office or Other Outpatient Visit for an Established Patient 99221-99223 Initial Hospital Care for a New or Established Patient 99238-99239 Hospital Discharge Day Management Services 99241-99245 Office or Other Outpatient Consultations, New or Established Patient 99251-99255 Initial Inpatient Consultations, New or Established Patient 99291-99292 Critical Care Services In the absence of one of these codes being reported with the –25 modifier and meeting the other requirements listed above, pay only the dialysis service and deny the evaluation and management service. Furthermore, payment is not allowed for more than one dialysis service per day.