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Renal Dialysis Benefits to Change Effective March 1, 2022

Last updated on 1/14/2022

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after March 1, 2022, renal dialysis benefits will change for Texas Medicaid.

The following list summarizes the changes to the benefit language:

  • Acute renal failure will be updated to acute kidney injury (AKI).
  • Method I or Method II will be updated to consolidated billing.

Composite Rate Payments

One of the following revenue codes must be billed for the dialysis facility to receive the composite rate payment for maintenance services or to receive the composite rate payment for clients being treated in the home setting.

Revenue Code

Limitations

821

3 per week

831

3 per week

841

Hemodialysis (HD) – equivalent sessions

851

HD – equivalent sessions

Consolidated Billing

The following laboratory procedure codes will be subject to end-stage renal disease (ESRD) consolidated billing:

Procedure Codes

80047^

80048^

80051^

80053^

80069^

80076

82040^

82108

82306

82310^

82330^

82374^

82379

82435^

82565^

82570^

82575

82607

82610

82652

82668

82728

82746

83540

83550

83735

83970

84075^

84100

84132^

84134

84155^

84157

84295^

84466

84520^

84540

84545

85014^

85018^

85025^

85027

85041

85044

85045

85046

85048

86704

86705

86706

87040

87070

87071

87073

87075

87076

87077

87081

87340

87341

G0306

G0307

G0499

     

QW^ Modifier

All drugs and biologicals used for the treatment of ESRD or AKI (unless specified otherwise) are included in the composite rate payment and are not paid separately. This includes the following procedure codes:

Procedure Codes

A4216

A4217

A4802

J0360

J0604

J0606

J0610

J0620

J0630

J0636

J0670

J0878

J0884

J0887

J0895

J0945

J1160

J1200

J1205

J1240

J1265

J1270

J1443

J1444

J1445

J1642

J1644

J1720

J1740

J1750

J1800

J1940

J1945

J1955

J2001

J2150

J2360

J2430

J2501

J2720

J2795

J2993

J2997

J2365

J3364

J3365

J3370

J3410

J3420

J3480

J3489

J7030

J7040

J7402

J7050

J7060

J7070

J7120

J7131

Q0613

Q5105

         

The following drug procedure codes that are used for the treatment of ESRD are excluded from the composite rate and will be paid separately:

Procedure Codes

J0882

J1439

J1756

J2916

Q0139

Q4081

Maintenance Hemodialysis

ESRD facilities that furnish dialysis treatments in-facility are paid up to 3 treatments per week. ESRD facilities that treat patients in the home setting, regardless of modality, receive payment for three hemodialysis equivalent treatments per week.

Maintenance Continuous Ambulatory Peritoneal Dialysis (CAPD) and Continuous Cycling Peritoneal Dialysis (CCPD)

For clients undergoing CAPD or CCPD in the home setting, the number of days of peritoneal dialysis, regardless of dialysate exchanges performed each day, is converted to hemodialysis-equivalent sessions. This is accomplished by dividing the number of days of peritoneal dialysis by 7 and multiplying the result by 3.

Revenue Code Updates

Revenue codes 845 and 855 will no longer be reimbursed for renal dialysis services.

The following revenue codes will no longer be reimbursed to the provider type at the listed places of service:

Revenue Code

Provider Type

Place of Service

634, 635, 636

Renal Dialysis Facility

Inpatient Hospital

636

Nephrology (Hemodialysis, Renal Dialysis)

Outpatient Hospital, Other Locations

The following provider types and places of service will no longer be reimbursed for revenue code 880:

Provider Type

Place of Service

Psychiatric Hospital, Renal Dialysis Facility, Rural Health Clinic – Hospital Based

Inpatient Hospital

Psychiatric Hospital, Nephrology (Hemodialysis, Renal Dialysis), Renal Dialysis Facility, Rural Health Clinic – Freestanding/Independent and Hospital Based

Outpatient Hospital

All Provider Types

Other Locations

The following diagnosis codes will be added and may be reimbursed for revenue codes 821, 829, 831, 839, 841, 849, and 851:

Diagnosis Codes

N1830

N1831

N1832

N990

T795XXA

T795XXD

T795XXS

         

Revenue codes 829, 839, 849, and 859 will be limited to one per day, any procedure, any provider.

Revenue codes 841 and 851 will be limited to three chronic renal disease (CRD) maintenance intermittent peritoneal dialysis (IPD) sessions per calendar week, any provider.

The following diagnosis codes will be added and may be reimbursed for revenue code 859:

Diagnosis Codes

N170

N171

N172

N178

N179

N181

N182

N1830

N1831

N1832

N184

N185

N186

N189

N990

T795XXA

T795XXD

T795XXS

Diagnosis codes N185 and N186 will be added and may be reimbursed for revenue code 880.

Procedure Codes

The following procedure codes will no longer be restricted by diagnosis:

Procedure Codes

36000

49421

78351

82040

82310

82374

82435

82565

83550

84075

84100

84132

84155

84520

85014

85018

85025

85041

93005

A4770

E1530

E1610

E1615

E1625

J0630

         

The following procedure codes will be denied when billed with procedure code G0257 and revenue code 880:

Procedure Codes

36000

36430

36591

36593

49421

93041

A4216

A4217

A4651

A4652

A4657

A4660

A4663

A4670

A4680

A4690

A4706

A4707

A4708

A4709

A4714

A4719

A4720

A4721

A4722

A4723

A4724

A4725

A4726

A4730

A4736

A4737

A4740

A4750

A4755

A4760

A4765

A4766

A4772

A4773

A4774

A4802

A4860

A4911

A4913

A4918

A4927

A4928

A4929

A4930

A4931

A4932

E0424

E0431

E0434

E0439

E1510

E1520

E1530

E1540

E1550

E1560

E1570

E1575

E1580

E1590

E1592

E1594

E1600

E1620

E1630

E1632

E1635

E1637

E1639

E1699

J0630

J1160

J1200

J1265

J1642

J1644

J1720

J1800

J1955

J2150

J2720

     

The following procedure codes will be denied when billed with procedure code G0257 and revenue codes 821, 829, 831, 839, 841, 849, 851, 859, and 880:

Procedure Codes

71045

71046

71047

71048

78300

78305

78306

80047

80048

80051

80053

80069

80076

81020

81050

82040

82108

82306

82310

82330

82374

82379

82435

82565

82570

82575

82607

82610

82652

82668

82728

82746

82947

83540

83550

83615

83735

83970

84075

84100

84132

84134

84155

84156

84157

84160

84295

84450

84466

84520

84540

84545

85004

85007

85008

85014

85018

85025

85027

85041

85044

85045

85046

85048

85345

85347

85610

86704

86705

86706

87040

87070

87071

87075

87076

87077

87081

87340

87341

87073

93000

93005

93040

95907

95908

95909

95910

95911

95912

95913

A4215

A4244

A4245

A4246

A4247

A4248

A4450

A4452

A6204

A6215

A6216

A6250

A6260

A6402

G0306

G0307

G0499

J0610

J0636

J0670

J0878

J0844

J0887

J0895

J1205

J1240

J1270

J1740

J1750

J1940

J2360

J2430

J2501

J2795

J2797

J3370

J3410

J3420

J3480

J3489

J7030

J7040

J7402

J7050

J7060

J7070

J7120

Q0163

Q5105

         

The following procedure codes will no longer be reimbursed to the specified provider types at the listed places of service:

Procedure Codes

Provider Type

Place of Service

71045, 71046

Nephrology (Hemodialysis, Renal Dialysis), Renal Dialysis Facility

Office, Nursing Home (Skilled Nursing Facility/Intermediate Care Facility), Outpatient Hospital, Nursing Home (Extended Care Facility)

78300, 78305, 78306

Nephrology (Hemodialysis, Renal Dialysis), Renal Dialysis Facility

Office, Inpatient Hospital, Outpatient Hospital, Independent Laboratory

81050

Nephrology (Hemodialysis, Renal Dialysis), Renal Dialysis Facility

Office

80069

Nephrology (Hemodialysis, Renal Dialysis), Renal Dialysis Facility

Outpatient Hospital

Procedure codes 71047, 95907, 95908, 95909, 95910, 95911, 95912, 95913, and 99001 will no longer be reimbursed to nephrology (hemodialysis, renal dialysis) and renal dialysis facility providers for services rendered in the office and outpatient hospital setting.

The following diagnosis codes will be added and may be reimbursed for procedure codes 90935, 90937, 90945, and 90947:

Diagnosis Codes

T795XXA

T795XXD

T795XXS

     

The following diagnosis codes will be added and may be reimbursed for procedure codes 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, and 90970:

Diagnosis Codes

N990

T795XXA

T795XXD

T795XXS

   

Procedure code 90966 will no longer be reimbursed to certified nurse midwife, registered nurse, and licensed midwife providers for services rendered in the inpatient hospital setting.

Procedure code E1575 will no longer be reimbursed to custom durable medical equipment (DME) providers for services rendered in any setting.

Procedure code E1530 will no longer be reimbursed to custom DME providers for services rendered in the home setting.

Procedure code E1635 will no longer be reimbursed to custom DME providers for services rendered in the office and home setting.

Procedure code G0257 will be limited to once per week, same procedure, any provider. Procedure code G0527 will be denied if not submitted with revenue code 880, same day, same claim, same provider.

For more information, call the TMHP Contact Center at 800-925-9126.