End stage renal disease (ESRD) billing reminders and quarterly updates
First Coast has seen inconsistencies in the reporting of ESRD claims. The beginning and ending service dates of the period should be included on one bill. 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.
Note: ESRD services are subject to the monthly billing requirements for repetitive services.
Common billing errors and how to resolve
Two common claim reason codes for ESRD sessions exceeding the limit:
Reason code 36362 - The services on this ESRD claim during the same month as a previously processed or in-process ESRD claim exceeded the limit routinely allowed for these dates of service.
- Refer to the Medicare Claims Processing Manual, Pub. 100-04, Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, Section 60.4.2 "Facility Billing Requirements for ESAs" under Maximum Allowable Administrations:
- The maximum number of administrations of erythropoietin EPO for a billing cycle is 13 times in 30 days and 14 times in 31 days.
- The maximum number of administrations of Aranesp for a billing cycle is 5 times in 30/31days.
Reason Code 36375 - The dialysis services on this ESRD claim during the same month as a previously processed or in-process ESRD claim, exceeded the limit routinely allowed for these dates of service.
- Refer to Local Coverage Determination (LCD) Frequency of Dialysis L35014 for dialysis services that are able to be exceeded with diagnosis related justification.
Data analysis identified the following common billing issues with ESRD claims:
Duplicate claims instead of adjustments
- When additional dialysis sessions are needed, some providers submit a second claim, this is often rejected as a duplicate. Instead, adjust the original processed claim to add the additional sessions.
Splitting monthly treatments across multiple claims
- Some providers bill one claim that exceeds the monthly treatment cap (with supporting justification) but then submit additional claims later in the same month. These follow-up claims are rejected due to missing justification. Instead, submit one claim for the entire month, including all sessions, and provide justification for any treatments over the maximum allowed along with the appropriate modifier.
ESRD billing quick checklist
One claim per month:
- All dialysis sessions for the month are combined into a single claim
- Avoid submitting multiple claims for the same month
- Adjust the original claim instead of submitting a new (duplicate) claim to add additional sessions
Sessions over the cap
- Clear justification included on the claim for treatments exceeding the maximum along with the appropriate modifier
ESRD quarterly updates
To view official ESRD quarterly updates, search the CMS Transmittals.
- Search using key words such as "Quarterly Update to the End Stage Renal Disease Prospective Payment System (ESRD PPS)"
Quarterly update Medicare Learning Network (MLN) articles.