Clinic Management

The unexpected perils of billing for PD services

A few missing words and a lack of understanding have combined to make reimbursement for PD services a difficult problem for dialysis providers. While CMS generally has a good understanding of how PD should be appropriately billed and reimbursed, the same cannot be said for commercial and other government payers, including those that provide Medicare Advantage plans. In my experience, there are outpatient dialysis providers that are not being fully reimbursed for their PD services and are not aware this is happening.

To identify and correct errors in PD reimbursement, this article focuses the problematic phrasing included in the current CMS coding manual and common misinterpretations that can take place in the CMS ESRD Benefit Policy Manual.

Problems with CMS wording

The reimbursement problems begin with poor wording in the CPT manual. In the manual’s section governing reimbursement for hemodialysis, it specifically states CPT codes 90935 and 90937 are to be used for “inpatient ESRD and non-ESRD procedures or for outpatient non-ESRD dialysis services.” Both codes have a physician component, leaving no doubt these are to be used for billing physician services related to these procedures.

Rick Collins

The CPT codes for PD services follow in the section immediately after hemodialysis. Unfortunately, instead of its own section, PD is lumped in with CPT codes for hemofiltration and continuous renal replacement therapies and the section is titled, “Miscellaneous Dialysis Procedures.” In that section, CPT code 90945 is defined as, “Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration or other continuous renal replacement therapies), with single evaluation by a physician or other qualified health care professional.” CPT code 90947 has essentially the same wording except it is used for visits requiring “repeated evaluation.” As both codes include physician components, it should be evident that these codes are intended to be used for billing physician services for inpatient ESRD and non-ESRD and outpatient non-ESRD services. However, that information was omitted from the explanatory paragraph preceding the definition of 90945 and 90947, where it clearly states the codes should only be used for inpatient ESRD and outpatient non-ESRD care. Without that wording in place, various payers and billers conclude 90945 and 90947 can be used for billing outpatient PD. However, when outpatient dialysis facilities bill for services, centers only bill for the technical components related to dialysis procedures; no physician services are included.

The ‘unlisted’ code

Physicians bill separately for their hospital and office visits, home training and in-person visits with patients on dialysis. CPT codes 90935 and 90937 and 90945 and 90947 are intended to appropriately describe physician services provided to renal patients. Physicians are not present when a PD patient dialyzes daily as part of their regular course of dialysis so billing for those services with codes that include one or more physician evaluations makes no sense.

Again, much of the reason for the confusion about which codes to use when billing for outpatient dialysis lies within the CPT manual. The only CPT code that exists for billing regular treatments for outpatient dialysis is 90999, “Unlisted dialysis procedure, inpatient or outpatient.” It is hard to comprehend that all of the outpatient treatments provided to ESRD patients every day are lumped under a code defined as “unlisted.” After decades of outpatient dialysis services, one would think CPT codes would have been created that are specific to outpatient hemodialysis and outpatient PD services. The failure to create such codes has cost renal providers millions of dollars over the years due to lost reimbursement from commercial and government payers. Most commercial payers have internal policies that discourage or forbid the payment of CPT codes defined as “unlisted.” This creates a huge problem for the outpatient dialysis industry. How can services be billed correctly when a payer refuses to reimburse for the only code that exists for providing those services? Most payers that refuse to reimburse for 90999 have chosen to require the use of 90935 or 90937 for outpatient hemodialysis and 90945 or 90947 for outpatient PD services. This begs the question of whether an outpatient dialysis provider should use a code for a single physician evaluation or for repeated evaluations when no physician evaluation occurred. When providers are placed in a position of having to choose procedure codes that do not accurately describe the services provided, bad things happen.

One of the more ridiculous examples of this occurs when a commercial payer denies reimbursement to a physician for a hospital visit because a dialysis facility has already been paid for that service. The opposite also occurs when an outpatient facility is denied payment because a physician “already billed for that same service.” The reasoning given by the commercial payer is that both providers are billing with the same code, eg, 90945, and therefore, only one provider can be paid. It can take weeks or months to resolve the issue with payers and in some cases, the commercial payer refuses to pay despite efforts made by the provider.

To its credit, CMS understands the only acceptable procedure code for billing outpatient dialysis for patients with ESRD is 90999. However, when Medicare calculates the allowed amount, it assigns to the patient a 20% co-insurance. Most patients with ESRD have a policy secondary to Medicare, but some secondary payers, including Medicaid in several states, do not determine how much it will reimburse based on the amount assigned by Medicare. Instead, these payers calculate how much they would have reimbursed for the services if they had been the primary payer. Once they calculate how much they would have reimbursed, they subtract the amount Medicare paid. This can cause a significant loss of reimbursement for providers when a secondary payer refuses to reimburse for 90999.

For example, if Medicare allows $3,000 for a patient’s monthly outpatient dialysis services, they would pay 80% or $2,400 and assign a patient co-insurance of $600. If the secondary payer refuses to reimburse for 90999, the amount they calculate as their responsibility is usually less than the amount Medicare paid as the primary payer. This results in a large co-insurance amount being billed to the patient each month, which is normally beyond the ability of the patient to pay. If the secondary payer is Medicaid, then the patient cannot be billed, and the provider simply loses the reimbursement.

While these scenarios defy common sense, these reimbursement issues occur every month across the United States. These problems could be resolved by the creation of CPT codes that are specific to outpatient dialysis services.

Number of treatments covered

Another issue plaguing PD providers is a misinterpretation of Section 50 of Chapter 11 of the Medicare Benefit Policy Manual. In the opening paragraph of 50.A, it states, “ESRD facilities furnishing dialysis in-facility or in a patient’s home are paid for a maximum of 13 treatments during a 30-day month and 14 treatments during a 31-day month unless there is medical justification for additional treatments.” This sentence has been used by payers to refuse reimbursing providers for more than 13 PD treatments per month.

The solution to overcoming this issue is found in the rest of the information in Section 50.A. It carefully explains that PD treatments are to be paid in hemo-equivalents and in paragraph 4, it clearly spells out how to calculate hemo-equivalents. The section also includes a table showing how PD treatments are to be calculated for reimbursement.

Another problem is being properly reimbursed for home dialysis training services. As I consult with providers, I am amazed at the number of payer contracts that either do not include home training or reimburse for training at the same rate as a regular treatment. Once again, CPT codes are part of the problem. For Medicare, home training is billed with 90999, but commercial payers and other government payers sometimes require the use of 90989 or 90993. CPT code 90989 is normally used by physicians to bill for their services related to a completed course of home training. CPT code 90993 is normally used by physicians to bill for a single training session. Several commercial payers especially smaller ones, do not correctly understand the codes, so reimbursement rates can vary wildly.

Protect yourself

Providers should act now to address each of the issues in this article. Review commercial contracts to see if 90945 or 90947 are required and their associated reimbursement. Make sure home dialysis training is included in your contracts and that the reimbursement is significantly higher than it is for standard treatments. Review Medicaid and military payers to see which PD codes are required and their accompanying reimbursement.

For providers in states where Medicaid does not accept the 20% co-insurance amount assigned by Medicare, review the Medicaid remittance advice for claims paid secondary to Medicare to determine how much is being allowed for PD and home training. Nephrologists should review their commercial reimbursement for professional services related to home dialysis training to ensure they are being reimbursed properly by Medicare Advantage Plans and traditional HMO and PPO policies.

Providers also will want to determine if any commercial payers are limiting their reimbursement for PD to 13 days per month. If so, use the Medicare Benefit Policy Manual, Chapter 2, Section 50A, to help overturn the payer’s erroneous policy. Finally, use your influence to demand specific CPT codes for outpatient dialysis to eliminate the confusion and lost reimbursement due to the use of CPT code 90999, “unlisted dialysis procedure, inpatient or outpatient.”

A few missing words and a lack of understanding have combined to make reimbursement for PD services a difficult problem for dialysis providers. While CMS generally has a good understanding of how PD should be appropriately billed and reimbursed, the same cannot be said for commercial and other government payers, including those that provide Medicare Advantage plans. In my experience, there are outpatient dialysis providers that are not being fully reimbursed for their PD services and are not aware this is happening.

To identify and correct errors in PD reimbursement, this article focuses the problematic phrasing included in the current CMS coding manual and common misinterpretations that can take place in the CMS ESRD Benefit Policy Manual.

Problems with CMS wording

The reimbursement problems begin with poor wording in the CPT manual. In the manual’s section governing reimbursement for hemodialysis, it specifically states CPT codes 90935 and 90937 are to be used for “inpatient ESRD and non-ESRD procedures or for outpatient non-ESRD dialysis services.” Both codes have a physician component, leaving no doubt these are to be used for billing physician services related to these procedures.

Rick Collins

The CPT codes for PD services follow in the section immediately after hemodialysis. Unfortunately, instead of its own section, PD is lumped in with CPT codes for hemofiltration and continuous renal replacement therapies and the section is titled, “Miscellaneous Dialysis Procedures.” In that section, CPT code 90945 is defined as, “Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration or other continuous renal replacement therapies), with single evaluation by a physician or other qualified health care professional.” CPT code 90947 has essentially the same wording except it is used for visits requiring “repeated evaluation.” As both codes include physician components, it should be evident that these codes are intended to be used for billing physician services for inpatient ESRD and non-ESRD and outpatient non-ESRD services. However, that information was omitted from the explanatory paragraph preceding the definition of 90945 and 90947, where it clearly states the codes should only be used for inpatient ESRD and outpatient non-ESRD care. Without that wording in place, various payers and billers conclude 90945 and 90947 can be used for billing outpatient PD. However, when outpatient dialysis facilities bill for services, centers only bill for the technical components related to dialysis procedures; no physician services are included.

The ‘unlisted’ code

Physicians bill separately for their hospital and office visits, home training and in-person visits with patients on dialysis. CPT codes 90935 and 90937 and 90945 and 90947 are intended to appropriately describe physician services provided to renal patients. Physicians are not present when a PD patient dialyzes daily as part of their regular course of dialysis so billing for those services with codes that include one or more physician evaluations makes no sense.

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Again, much of the reason for the confusion about which codes to use when billing for outpatient dialysis lies within the CPT manual. The only CPT code that exists for billing regular treatments for outpatient dialysis is 90999, “Unlisted dialysis procedure, inpatient or outpatient.” It is hard to comprehend that all of the outpatient treatments provided to ESRD patients every day are lumped under a code defined as “unlisted.” After decades of outpatient dialysis services, one would think CPT codes would have been created that are specific to outpatient hemodialysis and outpatient PD services. The failure to create such codes has cost renal providers millions of dollars over the years due to lost reimbursement from commercial and government payers. Most commercial payers have internal policies that discourage or forbid the payment of CPT codes defined as “unlisted.” This creates a huge problem for the outpatient dialysis industry. How can services be billed correctly when a payer refuses to reimburse for the only code that exists for providing those services? Most payers that refuse to reimburse for 90999 have chosen to require the use of 90935 or 90937 for outpatient hemodialysis and 90945 or 90947 for outpatient PD services. This begs the question of whether an outpatient dialysis provider should use a code for a single physician evaluation or for repeated evaluations when no physician evaluation occurred. When providers are placed in a position of having to choose procedure codes that do not accurately describe the services provided, bad things happen.

One of the more ridiculous examples of this occurs when a commercial payer denies reimbursement to a physician for a hospital visit because a dialysis facility has already been paid for that service. The opposite also occurs when an outpatient facility is denied payment because a physician “already billed for that same service.” The reasoning given by the commercial payer is that both providers are billing with the same code, eg, 90945, and therefore, only one provider can be paid. It can take weeks or months to resolve the issue with payers and in some cases, the commercial payer refuses to pay despite efforts made by the provider.

To its credit, CMS understands the only acceptable procedure code for billing outpatient dialysis for patients with ESRD is 90999. However, when Medicare calculates the allowed amount, it assigns to the patient a 20% co-insurance. Most patients with ESRD have a policy secondary to Medicare, but some secondary payers, including Medicaid in several states, do not determine how much it will reimburse based on the amount assigned by Medicare. Instead, these payers calculate how much they would have reimbursed for the services if they had been the primary payer. Once they calculate how much they would have reimbursed, they subtract the amount Medicare paid. This can cause a significant loss of reimbursement for providers when a secondary payer refuses to reimburse for 90999.

PAGE BREAK

For example, if Medicare allows $3,000 for a patient’s monthly outpatient dialysis services, they would pay 80% or $2,400 and assign a patient co-insurance of $600. If the secondary payer refuses to reimburse for 90999, the amount they calculate as their responsibility is usually less than the amount Medicare paid as the primary payer. This results in a large co-insurance amount being billed to the patient each month, which is normally beyond the ability of the patient to pay. If the secondary payer is Medicaid, then the patient cannot be billed, and the provider simply loses the reimbursement.

While these scenarios defy common sense, these reimbursement issues occur every month across the United States. These problems could be resolved by the creation of CPT codes that are specific to outpatient dialysis services.

Number of treatments covered

Another issue plaguing PD providers is a misinterpretation of Section 50 of Chapter 11 of the Medicare Benefit Policy Manual. In the opening paragraph of 50.A, it states, “ESRD facilities furnishing dialysis in-facility or in a patient’s home are paid for a maximum of 13 treatments during a 30-day month and 14 treatments during a 31-day month unless there is medical justification for additional treatments.” This sentence has been used by payers to refuse reimbursing providers for more than 13 PD treatments per month.

The solution to overcoming this issue is found in the rest of the information in Section 50.A. It carefully explains that PD treatments are to be paid in hemo-equivalents and in paragraph 4, it clearly spells out how to calculate hemo-equivalents. The section also includes a table showing how PD treatments are to be calculated for reimbursement.

Another problem is being properly reimbursed for home dialysis training services. As I consult with providers, I am amazed at the number of payer contracts that either do not include home training or reimburse for training at the same rate as a regular treatment. Once again, CPT codes are part of the problem. For Medicare, home training is billed with 90999, but commercial payers and other government payers sometimes require the use of 90989 or 90993. CPT code 90989 is normally used by physicians to bill for their services related to a completed course of home training. CPT code 90993 is normally used by physicians to bill for a single training session. Several commercial payers especially smaller ones, do not correctly understand the codes, so reimbursement rates can vary wildly.

PAGE BREAK

Protect yourself

Providers should act now to address each of the issues in this article. Review commercial contracts to see if 90945 or 90947 are required and their associated reimbursement. Make sure home dialysis training is included in your contracts and that the reimbursement is significantly higher than it is for standard treatments. Review Medicaid and military payers to see which PD codes are required and their accompanying reimbursement.

For providers in states where Medicaid does not accept the 20% co-insurance amount assigned by Medicare, review the Medicaid remittance advice for claims paid secondary to Medicare to determine how much is being allowed for PD and home training. Nephrologists should review their commercial reimbursement for professional services related to home dialysis training to ensure they are being reimbursed properly by Medicare Advantage Plans and traditional HMO and PPO policies.

Providers also will want to determine if any commercial payers are limiting their reimbursement for PD to 13 days per month. If so, use the Medicare Benefit Policy Manual, Chapter 2, Section 50A, to help overturn the payer’s erroneous policy. Finally, use your influence to demand specific CPT codes for outpatient dialysis to eliminate the confusion and lost reimbursement due to the use of CPT code 90999, “unlisted dialysis procedure, inpatient or outpatient.”