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2012 Texas Medicaid Provider Procedures Manual

Clinics and Other Outpatient Facility Services Handbook : 6. Renal Dialysis Facility : 6.2 Services, Benefits, Limitations, and Prior Authorization : 6.2.2 Renal Dialysis Facilities-Method I Composite Rate

The composite rate includes all necessary equipment, supplies, and services for the client receiving dialysis whether in the home or in a facility. The facility’s charge must not include the charge for the physician’s routine supervision. Examples of services included in the composite rate include, but are not limited to:
When one of these laboratory services is required more frequently, renal dialysis facility providers must submit the appropriate procedure code with modifier 91 for separate reimbursement.
Certain drugs such as those to elevate or decrease blood pressure, antiarrythmics, blood thinners or expanders, antihistamines or antibiotics to treat infections or peritonitis related to peritoneal dialysis are included in the composite rate. Examples include, but are not limited to:
Medically necessary drugs that are not included in the composite rate may be separately reimbursed when provided by and administered in the dialysis facility by facility staff. Staff time and supplies used to administer the drugs are included in the composite rate. Examples include, but are not limited to, the following:
Intravenous levocarnitine (procedure code J1955), for ESRD clients who have been on dialysis for a minimum of three months with one of the following indications (All other indications for levocarnitine are not covered.):
Signs and symptoms of erythropoietin-resistant anemia that has not responded to standard erythropoietin with iron replacement, and for which other causes have been investigated and adequately treated.
Hypotension on hemodialysis that interferes with delivery of the intended dialysis despite application of usual measures deemed appropriate (e.g., fluid management) (such episodes of hypotension must have occurred during at least two dialysis treatments in a 30-day period).
The ordering physician must maintain documentation in the client’s medical record to support medical necessity.

Texas Medicaid & Healthcare Partnership
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