Last Modified: 2/21/2024
Location: FL, PR, USVI
Business: Part A
First Coast found physicians or practitioners are incorrectly billing the following ESRD MCP claims prior to the end of the month or reporting only the last day of the month as the date of service:
• 90951-90962 (in-facility, full month) 90963-90966 (home dialysis, full month)
• 90967-90970 (home dialysis, partial month)
Therefore, effective February 4, 2019, ESRD MCP claims billed incorrectly will be rejected.
To avoid future rejections, please review the billing guidelines below.
The term 'month' means calendar month. The first month in which the beneficiary begins dialysis treatment marks the beginning of treatment through the end of the calendar month.
The physician or practitioner, who provides the complete assessment, establishes the patient's plan of care, and provides ongoing management, should be the one who submits the claim for the monthly services.
Submit a claim at the end of the month with the following information:
• Claim ‘date of service’ = first dialysis service date and the last dialysis service date of the month
• Use the appropriate procedure code for the patient's age and the number of visits for the month
This includes services:
• Personally furnished by a physician to an individual patient
• Contributing directly to the diagnosis and treatment of an individual patient
• Ordinarily performed by a physician
Example
A claim containing 90960 (ESRD related services monthly, patients 20 years of age and older; with four or more face-to- face visits) for dates of service 06/01/2016-06/30/2016 was received prior to 06/30/2016. Therefore, the physician / practitioner received payment for services not yet provided.
The claim should have been submitted upon completion of the billing month.
The CMS Pub. 100-04, Claims Processing Manual, Chapter 8, section 140.3 states: "Element 24A must show the dates of service during the month that are included in the MCP. The period includes the full calendar month the MCP physician or practitioner was responsible for the beneficiary's ESRD related care."
Reporting the dates of service to span the entire month allows other services, included or not included in the MCP, to process correctly.
Example
A claim for 90966 (home dialysis per full month; patients 20 years of age and older) was submitted with date of service 06/30/2016. However, the claim should have been submitted with dates of service that span the entire month, 06/01/2016-06/30/2016.
When billing for less than a full month of home dialysis, procedure code 90967, 90968, 90969 and 90970 should be used. The MCP should reflect the appropriate age for the ESRD-related service code and must document a face-to- face visit.
Example
When a patient receives home dialysis for 14 days and is hospitalized the remainder of the month use the age-appropriate CPT codes (90967-90970) and submit 14 units. The MCP must document a face-to- face visit.
• The physician or practitioner should bill for the age-appropriate home dialysis MCP service for the home dialysis if the MCP practitioner provides the following services:
• A complete monthly assessment of the ESRD beneficiary
• At least one face-to-face patient visit during the month
• Example, if a home dialysis patient was hospitalized during the month and at least one face-to-face outpatient visit and complete monthly assessment was furnished, the MCP practitioner should bill for the full home dialysis MCP service.
• The first month the beneficiary begins dialysis treatments, report the dates of service as the first date dialysis began through the end of the calendar month.
• When there is one or more face-to-face visits without a complete assessment of the patient and dialysis stopped due to death, per diem ESRD-related services should be coded using the ESRD related services (less than full month).
Note: MCP payment is made after the month has passed; we cannot pay a claim for ESRD services if billed on a claim with dates of service prior to the end of the month.
Professional claims shall presume that hospice benefits are not involved unless a GV or GW modifier is appended to the claim. Claims submitted without either the GV or GW modifier will deny when patients are enrolled in hospice.
Claims will deny for all other services related to the terminal illness furnished by individuals or entities other than the designated attending physician, who may be a nurse practitioner. These claims include bills for any DME, supplies or independently practicing speech-language pathologists or physical therapists that are related to the terminal condition. These services are included in the hospice rate and paid through the institutional claim.
Postmortem visits occurring on a date after the date of death are not to be reported. Hospices shall report hospice visits that occur before death on a separate line from those which occur after death. Date of death is defined as the date of death reported on the death certificate.
References
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
