Billing

When a Medicare patient needs dialysis, a clinic that is certified to provide home training and support can bill Medicare for a certain number of training sessions, depending on the modality:

After the initial training is over, changes in the home dialysis patient's circumstances may require retraining. If more training sessions are needed, there must be medical justification for Medicare to pay for them.

When Medicare WILL pay for retraining

Medicare will pay for home dialysis retraining if—despite the patient's change in circumstances—home dialysis is still an appropriate treatment for the patient, and only in these cases:

For more information, see Chapter 8, §50.8 in the Medicare Claims Processing Manual.

When Medicare WON'T pay for retraining

Medicare considers some services to be "retraining" and others to be expected home dialysis "support services." For example, if a PD patient develops peritonitis, the home training nurse may watch the patient perform PD connections/disconnections and catheter care using proper aseptic technique. Medicare considers this a home dialysis "support service"— not retraining. Other examples of home dialysis support services can be found under Chapter 11, §50.6 of the Medicare Benefit Policy Manual.

How to bill Medicare for retraining

The billing codes a clinic should use for retraining are the same codes as for training. Under the PPS, the reimbursement for a retraining day is the facility's base rate (unadjusted amount is $234.45 in 2012) plus the training rate per day ($33.44 wage adjusted). If a patient changes treatment from hemodialysis to CCPD and requires 2 days of retraining on the PD cycler, the facility could bill for 2 days of retraining and should bill the PD daily rate for the other 5 days that week. Remember, the daily rate for PD is the weekly rate divided by 7 [($234.45 x 3) รท 7 = $100.48].

Example:
2 PD training days [($234.45 + $33.44) x 2] $535.78
5 PD daily rate days ($100.48 x 5) $502.40
1 Week with 5 PD daily rate days plus 2 training days $1038.18

How much a clinic can bill for retraining

Medicare pays the same rate for retraining as it does for training. Just as in billing for training, the clinic can only bill the training rate or the standard treatment rate, and for one treatment per day . There are many resources to explain the new ESRD payment system.

For clinics that are billing entirely under the Prospective Payment System (PPS, or "the bundle")

The clinic should bill Medicare its usual hemodialysis rate plus the training add-on ($33.44 which is wage adjusted) if the patient needs retraining after the first 4 months of dialysis. When the Medicare beneficiary is eligible for the "onset of dialysis" adjustment, there is no adjustment for training or comorbidity. Medicare administrative contractors (MACs)/legacy fiscal intermediaries (FIs) are supposed to automatically adjust the facility's PPS rate for any treatment days within 120 days of the patient's first dialysis (as reported on the CMS 2728) that the patient has Medicare. The adjustment is 151% of the Medicare allowed reimbursement for that patient. The adjustment is only applied the first time a patient requires dialysis. It is not applied when a patient resumes dialysis after a failed transplant.

Example: Joe starts dialysis on December 15. He does not have Medicare at that time, but qualifies for it due to ESRD, not for any other reason:

For clinics transitioning with a blended payment of the composite payment system and PPS

Starting January 1, 2011, if a facility chose to transition into the PPS, the payment for retraining is under the composite rate plus the training rate of $20 for home hemodialysis or CCPD and $15 for CAPD.

Physician billing for retraining

Physicians can bill for training and retraining. The physician can bill $500 when a patient completes home training. If the patient does not complete training, the physician can bill $20 per training session up to $500. Here are the codes for physician billing for home dialysis training.

2012 CPT Code Long Descriptor
90989 Dialysis training, complete (bill with quantity 1; $500 allowed)
90993 Dialysis training, incomplete (enter # of sessions completed for quantity; based on 25 sessions at $20/session for $500)
90993 Retraining (for a different machine, different dialysis modality, change in setting, or change in dialysis partner; $20/session)

For physician reimbursement for training and retraining, see Chapter 8, §150 of the Medicare Claims Processing Manual.

The Renal Physicians Association provides coding and billing seminars to help physicians bill correctly.

Key Points