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:
- For CAPD, Medicare allows up to 15 training sessions based on 5–6 sessions a week with each session lasting up to 8 hours.
- For CCPD, Medicare allows up to 15 training sessions based on up to 5 exchanges per day 5–6 days a week.
- For home hemodialysis, Medicare routinely pays for up to 2 months of training based on 5-hour training sessions 3 times a week.
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:
- The patient changes to a different home modality
- The home dialysis equipment changes
- The setting where the home dialysis occurs changes
- The dialysis partner changes
- The patient has a change in medical status that would not keep him or her from doing home dialysis—but would require additional training (examples in the Medicare Claims Processing Manual include memory loss due to stroke, and physical impairment)
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) ÷ 7 = $100.48].
|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:
- If Joe signs up for Medicare and chooses in-center dialysis, his Medicare can start March 1. The clinic will get the onset of dialysis adjustment starting on March 1. Since December 15–February 28 was 75 days, the facility will only receive the onset adjustment for 45 days. If Joe decides later to train for home dialysis, the facility can receive the training fee for those days, and if he later needs retraining, the facility can receive payment for retraining at that time.
- If Joe signs up for Medicare and starts a home training program for PD or home HD before March 1, Joe's Medicare will be backdated to December 1 (the first day of the month dialysis started). His clinic can receive the onset of dialysis adjustment for all 120 days starting December 15, the first day of his dialysis. While receiving the onset of dialysis adjustment, his facility cannot bill for training or retraining.
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.
- Medicare can be backdated if a new dialysis patient chooses to train for home dialysis before the third full month of dialysis.
- A dialysis clinic is reimbursed more under the new onset of dialysis adjustment for all 120 days if a new dialysis patient has Original Medicare that whole time.
- Although the dialysis clinic cannot bill Medicare for training or retraining days during the first 120 days of dialysis, the new onset of dialysis adjustment offsets the cost of training more than the training/retraining rate.
- Home training that does not meet criteria for retraining is considered support services, and is not separately billable.
- Medicare will reimburse physicians for training and retraining days.
- Medicare manuals, the CMS Web site, and the Renal Physicians Association are resources to help you bill correctly.