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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 : Unscheduled or Emergency Dialysis in a Non-Certified ESRD Facility
For some medical situations in which ESRD clients cannot obtain their regularly scheduled dialysis treatment at a certified ESRD facility, Texas Medicaid will allow for non-routine dialysis treatments furnished in the outpatient department of a hospital that does not have a certified dialysis facility.
Unscheduled dialysis for clients may be a benefit for one of the following reasons:
Dialysis was performed following treatment for an unrelated medical emergency (e.g., a client goes to the emergency room and, as a result, misses a regularly scheduled dialysis treatment that cannot be rescheduled).
Providers must submit claims using procedure code G0257 with revenue code 880 in order to receive payment for unscheduled outpatient dialysis.
Procedure code G0257 is only reimbursed to clients with ESRD and must be billed with revenue code 880 on the same claim. If procedure code G0257 is not on the same claim as revenue code 880, it will be denied.
Procedure code G0257 is limited to diagnosis codes N185 and N186 and is limited to one service per day, any provider.
Erythropoietin (procedure code Q4081) may be billed separately and must be billed with revenue code 634 or 635 on the same claim.
Texas Medicaid will provide a single payment to reimburse unscheduled or emergency dialysis treatments furnished to ESRD clients in the outpatient department of a hospital that does not have a certified ESRD facility.
Reimbursement for procedure code G0257 is limited to the same services included in the Method 1 composite. Providers will not be reimbursed for individual services related to dialysis.
Repeated billing of this service by the same provider for the same clients may indicate routine dialysis treatments are being performed and providers will be subject to recoupment upon medical record review.
Reimbursement of other outpatient hospital services are only reimbursed if they are not related to the dialysis services and are determined to be medically necessary with supporting documentation.

Texas Medicaid & Healthcare Partnership
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