Skip to Main Content

Generally Accepted Dialysis Billing Guidelines Per CMS

Date: 03/14/18

Heritage Health (Medicaid):

The following are generally accepted dialysis billing guidelines per CMS. This is intended to be illustrative and is not an all-inclusive list.

Do’s

  • Indicate “72X” type of bill. The third digit is based on the type of claim (interim, corrected, etc.).
  • Hospital inpatient dialysis departments should bill with their hospital provider number and will be paid under the hospital agreement.
  • Bill one claim per calendar month except when training for the patient is provided or when hemodialysis is performed in the same month as peritoneal dialysis.
  • Bill a line item date of service for each revenue code billed on the claim form.
  • Revenue codes should be listed in ascending numeric order by date of service and line item billed.
  • Bill a separate line item for each dialysis session performed.
  • Separately billable drugs, including EPO should be line item billed. Include the line item date of service for the administration. Reimbursement will be calculated based on the units reported on the line.
    • The units reported on the line for each date dialysis (codes 821, 831, 841 and 851) was performed should not exceed one.
  • Report modifiers, occurrence codes, and condition codes.
  • Bill must include revenue codes and CPT codes for each line of service.
    • Example: When billing hemodialysis submit revenue code 821 with CPT code 90999.
  • The patient training rate includes the composite rate. Therefore, the composite rate should not be billed separately for days when training was provided.
  • Include patient date of birth.
  • Renal disease diagnosis code N18.6 (claim returned to Provider) as first diagnosis

Report modifiers, occurrence codes, and condition codes

  • HCPCS 90999 Requires Rev 082X with required modifier (V modifiers would need to be placed in front of the G modifiers).
  • The last date of service for the month on the claim must have V5, V6, or V7 modifier on it.
  • The route of administration of Erythropoiesis Stimulating Agents
    • Codes J0890, J0882, Q4054, Q4081, J0886 and Q4055
    • JA=intravenous, JB= subcutaneous and JE= via dialysate
    • Modifier “AY” (Non-ESRD Services) needed on Lab services, Drugs and Biologicals and certain Supplies
       
  • Procedure Q9976 requires modifier JE to be billed.
  • Height and weight should be reported for all ESRD patients (value codes)
    • A8 – Weight in kilograms
    • A9 – Height in centimeters
  • Use value Code D5 with 48 or 49.
    • Note: Cannot use value code 99.99 when billing for an ESA
       
  • Hemoglobin and/or hematocrit value(s) should be included.
  • Use occurrence Code 51.
  • At least one of the following condition codes should be included: 71, 72, 73, 74, 76, 80 or 59 (claim returned to the provider)

Don’t

  • Do not submit claims that cross over from one month to the other. Example: Service dates in January should be on one claim and service dates in February should be on another claim.

  • Do not bill for hemodialysis and peritoneal dialysis composite rates on the same claim. In this situation, you must bill a claim for each type of dialysis provided within the same calendar month. Dates of service must not overlap.


As always, please verify codes on the prior authorization tool to ensure a prior authorization is not required for services rendered.