Dialysis and ESRD Billing Services

ESRD Billing Overview

Dialysis billing runs on two separate tracks. The facility is paid a bundled per-treatment amount under the ESRD prospective payment system for the dialysis itself, including the drugs, laboratory services and supplies related to maintenance dialysis. The physician or practitioner who manages the patient is paid separately, once per calendar month, under the monthly capitation payment. Getting either track wrong tends to produce recoveries rather than simple denials, because the payment has usually already been made by the time a visit count or setting is questioned. The two tracks are billed by different entities on different claim types, which is why a dialysis center and a nephrology group can both be clients on the same patient. The office side of the same practice is covered under nephrology billing.

Monthly Capitation Payments

• One monthly capitation service is reported per patient per calendar month. In the first month of dialysis the month runs from the date treatments begin to the end of that calendar month.
• The claim is submitted by the physician or practitioner who provides the complete assessment, establishes the plan of care and provides the ongoing management, even when partners or employed practitioners furnish some of the visits.
• When a nurse practitioner, clinical nurse specialist or physician assistant performs the complete assessment and sets the plan of care, the monthly service is submitted under that practitioner.
• Visits must be face-to-face and furnished by a physician, clinical nurse specialist, nurse practitioner or physician assistant. Each visit in the month needs its own signed note.
• The capitation is paid to the designated managing physician whether the patient dialyzes at home or in an approved facility. Setting changes the code reported, not who receives the payment.

90960-Series Coding

The monthly codes are age specific and visit-count specific, and the age used is the patient age at the end of the month. For patients 20 years of age and older dialyzing in a center, 90960 reports four or more face-to-face visits, 90961 reports two to three visits, and 90962 reports one visit. Patients under 20 use the corresponding age-banded codes in the 90951 to 90959 range. Home dialysis patients are reported once monthly with 90963 to 90966. Partial months are reported per day with 90967 to 90970 and the number of days as units, for example a patient who dialyzed at home for 14 days and was hospitalized for the rest of the month is reported with 14 units of the age-appropriate per-day code. Only one code from the 90951 to 90966 range is paid per month regardless of how many physicians saw the patient. Our medical coding team assigns the code from the signed visit notes, never from the appointment schedule.

Facility vs Professional Dialysis Claims

• Facility claim: the dialysis facility bills on the institutional 72x type of bill under the ESRD prospective payment system. Payment is a bundled per-treatment rate that covers the session and the related drugs, laboratory services and supplies. Condition code 84 separates an ESRD claim from an acute kidney injury claim.
• Professional claim: the managing physician or practitioner bills the monthly capitation code on a professional claim, with patient age and the documented visit count driving code selection.
• Hospital inpatient dialysis is covered under Part A and follows inpatient payment rules, so inpatient days are handled differently from outpatient months. Where the facility is a hospital, that side is covered by hospital billing services.
• Services that fall outside the facility bundle and outside the monthly capitation can still be billed separately where documented. Identifying those without billing an item that is already bundled is the reconciliation work.
• Both tracks follow Medicare billing rules first, then the variations that commercial plans and Medicaid managed care apply.

Denial Prevention

• Reconcile the treatment log to the claim every month. The visit count on the claim has to match signed face-to-face notes, not the schedule. Four or more visits per month is a Recovery Audit Contractor review topic, so 90960 in particular needs every note in place before submission.
• Track setting changes as they happen. A patient moving between home and in-center dialysis changes the code family for that month, and billing from a static patient list gets it wrong.
• Adjust for hospitalizations. Inpatient days are not outpatient capitation days, and a full-month code on a partial month is a recovery waiting to happen.
• Never add late signatures. Medicare requires signed orders and a signed note for every visit. A missing signature is handled through the attestation process, not by back-dating the record.
• Work visit-count and setting denials with the treatment record attached, through denial management, rather than resubmitting the same claim.