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December 2016 Texas Medicaid Provider Procedures Manual

Clinics and Other Outpatient Facility Services Handbook : 6 Renal Dialysis Facility : 6.2 Services, Benefits, Limitations, and Prior Authorization : 6.2.1 Physician Supervision

6.2.1
Physician reimbursement for supervision of ESRD clients on dialysis is based on a monthly capitation payment (MCP) that is calculated by Medicare. The MCP is a comprehensive payment that covers all of the physician services that are associated with the continuing medical management of a maintenance dialysis client for treatments received in the facility. An original onset date of dialysis treatment must be included on claims for all renal dialysis procedures in all places of service except inpatient hospital.
Physician supervision of outpatient ESRD dialysis includes services that are rendered by the attending physician in the course of office visits during which any of the following occur:
Services that are involved in the prescription of therapy for illnesses that are unrelated to renal disease, if the treatment occurs without increasing the number of physician-client contacts
The following physician services are a benefit for physician supervision of outpatient ESRD dialysis services:
 
Procedure codes 90935, 90937, 90945, and 90947 are a benefit for:
ESRD or non-ERSD services in the inpatient setting when the physician is present during dialysis treatment. The physician must be physically present and involved during the course of dialysis. These codes are not payable for a cursory visit by the physician. Hospital visit procedure codes must be used for a cursory visit.
Only one of the following procedure codes 90935, 90937, 90945, or 90947 may be reimbursed per day by any provider.
If the physician sees the client only when the client is not dialyzing, the physician must submit the appropriate hospital visit procedure code. The inpatient dialysis procedure code must not be submitted for payment.
Providers must use one of the following procedure codes to submit claims for services when the client:
.
When a full calendar month of ESRD-related services are submitted for clients on home dialysis, providers must use procedure code 90963, 90964, 90965, or 90966.
Providers must submit claims with procedure code 90967, 90968, 90969, or 90970 if ESRD-related services are provided for less than a full month, per day, under the following conditions:
Procedure codes 90967, 90968, 90969, and 90970 are limited to one per day by any provider. When submitting claims for these procedure codes, providers must indicate the dates of service on which supervision was provided.
Procedure codes 90967, 90968, 90969, and 90970 will be denied if they are submitted with dates of service in the same calendar month by any provider as the following procedure codes:
 
Only one of the procedure codes in the previous table will be reimbursed per calendar month by any provider.
The following services may be provided in conjunction with physician supervision of outpatient ESRD dialysis but are considered nonroutine and may be submitted for reimbursement separately.
If one of the following occurs:
Then the physician must submit both of the following:
If a client has a complete assessment in the month during which the client is hospitalized, one of the following procedure codes must be submitted for the month of supervision:
 
The appropriate inpatient evaluation and management codes must be reported for procedures provided during the hospitalization.
Dialysis at an outpatient facility other than the usual dialysis setting for a client of a physician who bills the MCP. The physician must submit procedure code 90967, 90968, 90969, or 90970 for each date on which supervision is provided. The physician may not submit claims for days that the client dialyzed elsewhere.
Physician services beyond those that are related to the treatment of the client’s renal condition that cause the number of physician-client contacts to increase. Physicians may submit claims on a fee-for-service basis if they supply documentation on the claim that the illness is not related to the renal condition and that additional visits are required.
Inpatient services that are provided to a hospitalized client for whom the physician has agreed to submit monthly claims, may be reimbursed in one of the following ways:
The physician may elect to continue monthly billing, in which case the physician may not bill for individual services that were provided to the hospitalized client.
The physician may reduce the monthly amount submitted by 1/30th for each day of hospitalization and may charge fees for individual services that were provided on the hospitalized days.
The physician may submit a claim for inpatient dialysis services using the inpatient dialysis procedure codes. The physician must be present and involved with the client during the course of the dialysis.
Clients may receive dialysis at an outpatient facility other than the client’s usual dialysis setting, even if their physician bills for monthly dialysis coordination. The physician must reduce the monthly amount submitted for reimbursement by 1/30th for each day the client is dialyzed elsewhere.
Physician services beyond those related to the treatment of the client’s renal condition may be reimbursed on a fee-for-service basis. The physician must provide medical documentation with the claim that identifies how the illness is not related to the renal condition and added visits are required.
Payment is made for physician training services in addition to the MCP for physician supervision rendered to maintenance facility clients.

Texas Medicaid & Healthcare Partnership
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