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...everything you need to know about doing dialysis at home.
We've gathered up-to-date information on reimbursement for treatments, home equipment, training, travel, physician billing codes, and more, prepared by national expert Beth Witten, MSW, ACSW, LSCSW.
Click on any question to go directly to the answer. After each response, you may click "back to top" to choose another question and answer.
About 9% of those on dialysis are currently doing some type of home dialysis. In 1973 before Medicare started paying for dialysis, about 60% of those on dialysis did it at home.
Many people wonder what factors have contributed to the decline in home dialysis. One study of U.S. nephrologists found that doctors who have been in practice for 11 or more years were significantly less likely to recommend PD (Thamer M, et al. U.S. nephrologists’ recommendation of dialysis modality: Results of a national survey. Am J Kidney Dis. 36(6):1155–65,2000). Those who did recommend PD were significantly more likely to refer patients who still had some residual renal function and were:
Study authors expressed the concern that if nephrologists continue to use these factors as determinants, the growing incidence of diabetes, obesity, malnutrition, patients living alone, and substance abuse could limit the future use of PD.
Another study of practicing nephrologists found that respondents (47% of the total) believed PD and home hemodialysis were underutilized. In fact, they believed that 11–14% of patients could do home hemodialysis and 26–39% of patients could do PD (Mendelssohn DC, et al. What do American nephologists think about dialysis modality selection? Am J Kidney Dis. 37(1):22–29,2001).
These physicians stated that the following are factors to consider in modality selection (in order from highest to least important):
Medicare has added a benefit for chronic kidney disease education that can be provided by certain approved providers, including physicians and non-physician practitioners. One of the objectives is to assure that individuals who have stage-4 CKD are informed about how to manage their disease and what treatment options for kidney failure exist. Also, the ESRD Conditions for Coverage require that all dialysis patients be informed about all treatment options, including those not offered at their clinic.
Any clinic that wants to be paid for training and supporting home dialysis patients must be Medicare certified.
The clinic wanting to be certified sends a completed CMS 855A form to the Medicare contractor that it bills for in-center claims. The Medicare contractor reviews the form and notifies the State Survey Agency when they approve the request. Once this form is approved and the clinic notifies the State Survey Agency that they are ready for survey, the State Survey Agency will add the clinic to their list of surveys to be conducted. Once the survey is successfully completed, the State Survey Agency will recommend to CMS to add the service of home training and support services for HD and/or PD (depending upon what is requested/approved).
To be certified, the clinic must meet all the relevant requirements in the Conditions for Coverage, including a whole Condition for Care at Home that describes the requirements for training, staffing, equipment and supply maintenance, water and dialysate quality for home HD, medical records, emergency call, etc. In all areas, the clinic is expected to make sure that home patients receive at least the same level of care that in-center patients receive.
The dialysis regulations require the training nurse to teach patients (and helpers, if needed) about the following topics:
The Medicare Claims Processing Manual, Chapter 8 on ESRD provides explanations and help for billing for home dialysis to include what the Medicare rate covers, condition codes, occurrence codes, value codes, and the following revenue codes:
See Chapter 8 of the Medicare Claims Processing Manual §50 and §80 for billing composite rate for ESRD home dialysis services, including billing for training and re-training.
See Chapter 25 of the Medicare Claims Processing Manual for general instructions for completing the CMS-1450 (UB-04) or ANSI X12N formats.
The physician is reimbursed $500 (subject to Medicare’s Part B annual deductible and coinsurance) for supervising the training of each home-trained patient. This payment is made in addition to the MCP rate. If the patient does not complete training, the physician’s training fee is $20 per training session.
Physicians can receive the training supervision fee in addition to their MCP payment if a patient requires retraining due to a change in home modality, a change in machine to one he/she has not been trained to use, a change in the setting for dialysis, or a change in dialysis partner.
See Chapter 8 of the Medicare Claims Processing Manual §150.
Medicare pays physicians and non-physician practitioners (advanced practice registered nurses and physician assistants) who follow home dialysis patients a monthly rate called the monthly capitated rate (MCP). The rate is based on the age of the patient. The management of home dialysis patients who remain a home dialysis patient the entire month should be coded using the ESRD-related services for home dialysis patients HCPCS codes. These are the codes to use:
|MCP Code||Long Descriptor|
|90963||ESRD-related services for home dialysis per full month, for patients younger than 2 years of age|
|90964||ESRD-related services for home dialysis per full month, for patients 2–11 years of age|
|90965||ESRD-related services for home dialysis per full month, for patients 12–19 years of age|
|90966||ESRD-related services for home dialysis per full month, for patients 20 years of age or older|
|90967||ESRD-related services for dialysis less than a full month of service, per day for patients younger than 2 years of age|
|90968||ESRD-related services for dialysis less than a full month of service, per day for patients 2–11 years of age|
|90969||ESRD-related services for dialysis less than a full month of service, per day for patients 12–19 years of age|
|90970||ESRD-related services for dialysis less than a full month of service, per day for patients 20 years of age or older|
These are the codes that physicians should use to bill for home training:
|MCP 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.
If you have further questions about physician billing for home dialysis, your Medicare carrier would be a good resource.
The expectation is that the physician will have, and document in the patient’s medical record, at least one face-to-face visit per month with the home dialysis patient to get the monthly capitated payment. Medicare contractors may occasionally waive the requirement for a monthly face-to-face visit for the home dialysis monthly capitated payment (MCP) on a case-by-case basis, for example, when the nephrologist’s notes indicate that he/she actively and adequately managed the care of the home dialysis patient throughout the month.
See Chapter 8 of the Medicare Claims Processing Manual §140.1.1.
If the same physician continues to manage the patient’s care all month when he/she switches from home to in-center dialysis temporarily, the physician should bill the MCP rate for the home patient for the full month and should not bill the rate for managing an in-center patient.
See Chapter 8 of the Medicare Claims Processing Manual §140.1.2.
The physician should bill on a per-diem basis. Situations where this may occur include:
See Chapter 8 of the Medicare Claims Processing Manual §140.2.
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