End-stage renal disease (ESRD) billing requirements

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Home ► Billing news ► End-stage renal disease (ESRD) billing requirements

Last Modified: 6/21/2024 Location: FL, PR, USVI Business: Part A

End-stage renal disease (ESRD) billing requirements

Below is an overview of the most common billing requirements; it is not meant to be all-inclusive. There may be other ESRD-related services that are billed using codes that may not be reflected here.

Billing requirements

Submit your monthly ESRD services on a 72X type of bill (TOB).

Statement covers from and through dates

The beginning and ending service dates of the period should be included on one bill. Note: ESRD services are subject to the monthly billing requirements for repetitive services.

The statement covers 'from' and 'through' dates must reflect the first day dialysis began in the billing month through the last day of dialysis in the billing month.

• Example: 03/03/22-03/27/22, not 03/01/22-03/31/22

Line-item detail billing is required for ESRD claims. Each service must be submitted on a separate line with the appropriate line-item date of service. The Medicare standard systems perform line-item date of service compare for ESRD claims with statement billing periods overlapping the statement billing period of another processed claim. This prevents monthly claims from receiving overlapping edits based on the statement billing period dates but rather, only when the ESRD claim has a line item that duplicates another processed claim.

Diagnosis codes

Report a principal diagnosis and any other diagnosis codes for co-morbidity conditions (if applicable).

The lists of the comorbidity categories and diagnosis codes are found on the CMS website in the ESRD prospective payment system (PPS) patient-level adjustments site under downloads:

• ESRD PPS Comorbidity Categories and Diagnostic Codes external link

Condition codes

ESRD claims must have one dialysis condition code per claim to describe the dialysis setting. If two dialysis settings are used during the month, then two claims must be filed. It is recommended to submit each claim for the full range of dates of service that are applicable to each type of dialysis through each last day of dialysis that was performed in the billing month.

Condition code	Definition
71	Full care in unit or transient
72	Self-care in unit
73	Training
74	Home
76	Backup in-facility dialysis

Other optional condition codes

Condition code	Definition
59	Non-primary ESRD facility
70	Self-administered anemia management drug [Erythropoietin (EPO)]
80	ESRD beneficiary receiving home dialysis in nursing facilities, including skilled nursing facilities (report along with condition code 74)
84	Acute kidney injury (AKI) on a monthly basis
86	Additional hemodialysis treatments with medical justification
87	Self-care retraining
H3	Gastrointestinal (GI) bleeding
H4	Pneumonia
H5	Pericarditis

Occurrence code

Report occurrence code 51 - Date of last Kt/V (K-dialyzer clearance of urea; t-dialysis time; V-patient’s total body water) reading

• In-center hemodialysis patients

• Date of last reading taken during the billing period

• Peritoneal dialysis patients and home hemodialysis patients

• Date may be before the current billing period, but within four months of the date of service on the claim

Report occurrence code 33 - First day of coordination period covered by employer group health plan

• Must be used in combination with value code 13 when Medicare is the secondary payer due to ESRD entitlement

Value codes/amounts

Value Code	Definition
48	Hemoglobin reading
49	Hematocrit reading
A8	Weight of patient (in kilograms)
A9	Height of patient (in centimeters)
D5	Result of last Kt/V reading

Revenue codes

Revenue code	Definition
0634	EPO, less than 10,000 units administered
0635	EPO, 10,000 units or more administered
0636	Darbepoetin Alfa and drugs requiring specific information
082X	Hemodialysis
083X	Peritoneal dialysis
084X	Continuous Ambulatory Peritoneal Dialysis (CAPD)
085X	Continuous Cycling Peritoneal Dialysis (CCPD)
0881	Ultrafiltration, performed separately from dialysis treatment

HCPCS reporting

Report the appropriate HCPCS (not all-inclusive list), when applicable.

HCPCS	Definition	Frequency
90999	Unlisted dialysis procedure, inpatient or outpatient	Billable three times per week; 13 times in 30 days and 14 times in 31 days
J0882	Injection, Darbepoetin Alfa, 1mcg (for ESRD on dialysis) (Aranesp)	Maximum number of administrations of Aranesp for a billing cycle is five times in 30 or 31 days
Q4081	Injection, Epoetin alfa, 100 units (for ESRD on dialysis)	Maximum number of administrations of EPO for a billing cycle is 13 times in 30 days and 14 times in 31 days

Modifiers

Modifiers	Definition
AX	Item furnished in conjunction with dialysis services
AY	Item or service furnished to an ESRD patient that is not for the treatment of ESRD
CG	Policy criteria applies (report with revenue codes 0821 or 0881 and HCPCS 90999 when billing dialysis treatments in excess of the 13 or 14 monthly allowable treatments)
ED	Hematocrit greater than 39.0% or hemoglobin greater than 13.0g/dL for 3 or more consecutive billing cycles immediately prior to and including the current billing cycle
EE	Hematocrit greater than 39.0% or hemoglobin greater than 13.0g/dL for less than 3 consecutive billing cycles immediately prior to and including the current billing cycle
EJ	Subsequent claims for a defined course of therapy, e.g., EPO, sodium hyaluronate, infliximab
EM	Emergency reserve supply
ET	Emergency services
GS	Dosage of EPO or Aranesp has been reduced and maintained in response to hematocrit or hemoglobin level
G1	Most recent Urea Reduction Ratio (URR) of less than 60%
G2	Most recent URR of 60% to 64.9%
G3	Most recent URR of 65% to 69.9%
G4	Most recent URR of 70% to 74.9%
G5	Most recent URR of 75% or greater
G6	ESRD patient for whom less than seven dialysis sessions have been provided in a month
JA	Administered intravenous
JB	Administered subcutaneous
JW	Drug amount discarded/not administered
Q3	Kidney donor services
UJ	Services provided at night
V5	Any vascular catheter (alone or with any other vascular access) Note: ESRD claims for hemodialysis must indicate the type of vascular access used for the delivery of the hemodialysis at the last hemodialysis session of the month. A code is required to be reported on the latest line-item date of service billing for hemodialysis revenue code 0821. It may be reported on all revenue code 0821 lines at the discretion of the provider.
V6	Arteriovenous graft (or other vascular access, not including a vascular catheter) Note: ESRD claims for hemodialysis must indicate the type of vascular access used for the delivery of the hemodialysis at the last hemodialysis session of the month. A code is required to be reported on the latest line-item date of service billing for hemodialysis revenue code 0821. It may be reported on all revenue code 0821 lines at the discretion of the provider.
V7	Arteriovenous fistula only (in use with two needles) Note: ESRD claims for hemodialysis must indicate the type of vascular access used for the delivery of the hemodialysis at the last hemodialysis session of the month. A code is required to be reported on the latest line-item date of service billing for hemodialysis revenue code 0821. It may be reported on all revenue code 0821 lines at the discretion of the provider.

Billing and coding overview

Revenue code	Frequency	Condition code	Value code	Monthly limit
0634- EPO<10,000 or 0635- EPO>10,000	Three times per week	N/A	48 and/or 49	13 times in 30 days/ 14 times in 31 days
0636- Darbepoetin Alfa (DPO) (Aranesp)	N/A	N/A	48 and/or 49	Five times per month
082X- Hemodialysis	Three times per week	71, 72, 73, 74, 76	A8, A9, D5	13 times in 30 days/ 14 times in 31 days
083X- Peritoneal dialysis	Three times per week	71, 72, 73, 74, 76	A8, A9, D5	13 times in 30 days/ 14 times in 31 days
084X- CAPD	Daily	73 or 74	A8, A9, D5	13 times in 30 days/ 14 times in 31 days
085X- CCPD	Daily	73 or 74	A8, A9, D5	13 times in 30 days/ 14 times in 31 days

HCPCS paid outside of the ESRD PPS with an effective date mid-month, or a fee schedule rate change mid-month

The Fiscal Intermediary Shared System (FISS) uses the “from date” instead of the line-item date of service on ESRD PPS claims to determine how to process HCPCS not paid under the ESRD PPS.

When billing a HCPCS not covered under ESRD PPS, the ESRD claim should be split based on the effective date of the change to the HCPCS.

If a HCPCS rate changes mid-month, the claim should be billed split to allow the correct rate to be applied or if the service is able to be submitted alone, i.e., COVID or flu codes, submit the service on a 72X claim by itself.

• Example split claim: HCPCS rate changed on 05/19/22

• First claim should be billed from 05/01/22-05/18/22.

• Second claim should be billed from 05/19/22-05/31/22 with the HCPCS on the 05/19/22-05/31/22 claim.

• This will allow FISS to apply the correct rate based on the 05/19/22 “from date.”

• Example split claim: HCPCS effective date 05/03/22

• First claim should be billed from 05/01/22-05/02/22.

• Second claim should be billed from 05/03/22-05/31/22 with the HCPCS on the 05/03/22-05/31/22 claim.

• This will prevent the service from receiving a reason code for invalid HCPCS based on the 05/03/22 “from date.”

• Example claim with HCPCS by itself: HCPCS rate changed 05/19/22

• The HCPCS should not be reported on the ESRD PPS claim. Bill normal ESRD PPS claim with from 05/01/22-05/31/22.

• For the HCPCS with the rate change, submit the 72X claim with just the date of service the HCPCS was provided, for example from 05/25/22-05/25/22 with any appropriate additional coding that may be required for the specific HCPCS.

• This will allow FISS to apply the correct rate based on the “from date.”

Refer to our ESRD webpage for more information and resources available.

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