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).

Type of bill acceptable codes for Medicare are:

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: 03/03/24-03/27/24, not 03/01/24-03/31/24

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

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. 

Other optional condition codes

Occurrence code (not all-inclusive list)

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

Revenue codes 

HCPCS reporting

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

Modifiers

Billing and coding overview

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
  • First claim should be billed from 05/01-05/18
  • Second claim should be billed from 05/19-05/31 with the HCPCS on the 05/19-05/31 claim.
    • This will allow FISS to apply the correct rate based on the 05/19 “from date.”
• Example split claim: HCPCS effective date 05/03
  • First claim should be billed from 05/01-05/02.
  • Second claim should be billed from 05/03-05/31 with the HCPCS on the 05/03-05/31 claim.
    • This will prevent the service from receiving a reason code for invalid HCPCS based on the 05/03 “from date.”
• Example claim with HCPCS by itself: HCPCS rate changed 05/19
  • The HCPCS should not be reported on the ESRD PPS claim. Bill normal ESRD PPS claim with from 05/01-05/31
  • For the HCPCS with the rate change, submit the 72X claim with just the date of service the HCPCS was provided, for example from 05/25-05/25 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.