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31.3.1 In-Facility Services and Method I Home Dialysis Services
Outpatient dialysis is furnished on an outpatient basis at a renal dialysis center or facility.
Allowable outpatient dialysis services include:
• Staff-assisted dialysis performed by the center's or facility's staff.
•Self-dialysis performed by a client with little or no professional assistance, provided that the client has completed an appropriate course of training.
•In-home dialysis performed by an appropriately trained client or an appropriately trained caregiver.
•Dialysis services provided in an approved renal dialysis facility on an outpatient basis.
The facility's composite rate is a comprehensive daily payment for all in-facility and Method I home dialysis. The cost of an item or service is included under this rate unless specifically excluded, such as physician's professional services, lab work that is designated as separately billable, and drugs designated as separately billable. Providers should bill the following revenue codes for Method I on a daily basis:
The composite rate includes all necessary equipment, supplies, and services for the client receiving dialysis whether in the home or in a facility.
Refer to: Section 31.5, "Reimbursement" for additional information about the Method I composite rate.
Examples of services that are not separately payable include, but are not limited to:
•Dialysate (procedure codes A4720, A4721, A4722, A4723, A4724, A4725, A4726, and A4765)
•Cardiac monitoring (procedure codes 93040 and 93041)
•Catheter changes (procedure codes 36000, 49420, and 49421)
•Suture removal or dressing changes
•Crash cart usage for cardiac arrest
•Declotting of shunt performed by facility staff for hemodialysis (procedure code 36593)
•Oxygen (procedure codes E0424, E0431, E0434, E0435, E0439, E0440, E0441, E0442, E0443, and E0444)
•Staff time to administer blood, separately billable drugs, and blood collection for laboratory (procedure codes 36430 and 36591)
•Routine laboratory services for dialysis (listed in the table below) are included in the composite rate and not billed separately
•When additional in-facility laboratory testing is medically necessary beyond the routine frequencies identified below, providers must bill using Current Procedural Terminology (CPT) modifier 91. Documentation supporting medical necessity must be maintained in the client's medical record by the client's physician and the renal dialysis center.
In addition to the services listed above, certain drugs such as those to elevate or decrease blood pressure, antiarrythmics, blood thinners or expanders, antihistamines, or antibiotics to treat catheter site infections or peritonitis, are included in the composite rate. Examples include, but are not limited to:
•Dextrose (procedure codes J7042, J7060, and J7070)
•Digoxin (procedure code J1160)
•Diphenhydramine (procedure code J1200)
•Dopamine (procedure code J1265)
•Glucose
•Heparin (procedure codes J1642 and J1644)
•Hydralazine (procedure code J0360)
•Hydrocortisone sodium succinate (procedure code J1720)
•Insulin
•Lidocaine, bupivacaine (procedure code J2001)
•Mannitol (procedure code J2150)
•Norepinephrine bitartrate
•Procaine
•Propranolol (procedure code J1800)
•Protamine (procedure code J2720)
•Saline (procedure codes A4216, A4217, A4218, J7030, J7040, J7042, J7050, and J7130)
•Verapamil
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