Renal Dialysis Benefits to Change for CSHCN September 1, 2023

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Effective for dates of service on or after September 1, 2023, renal dialysis benefits will change for the Children with Special Health Care Needs (CSHCN) Services Program.

Overview of Benefit Changes

The changes to the renal dialysis benefits include:

• New and end-dated benefits
• Consolidated billing
• Authorization not required for renal dialysis services
• Diagnosis codes restrictions
• Provider type and place of service updates

Home Dialysis Items and Services

Texas Medicaid uses Medicare’s composite rate reimbursement system for consolidated billing. Under this reimbursement system, the dialysis facility is responsible for providing all home dialysis equipment, supplies, and home services support.

Benefit Criteria

Procedure code E0210 will become a benefit for clients of all ages and may be reimbursed to medical supplier (DME), medical supply company, and custom DME providers for services rendered in the office setting and medical supply company providers for services rendered in the home setting.

Procedure codes J7030, J7040, J7042, J7050, J7060, J7070, and J7120 will become benefits for clients of all ages and may be reimbursed to physician assistant, nurse practitioner, clinical nurse specialist, physician, and nephrology (hemodialysis, renal dialysis) providers for services rendered in the office setting and hospital, nephrology (hemodialysis, renal dialysis), and renal dialysis facility providers for services rendered in the outpatient hospital setting.

Procedure codes Q0163 and Q5105 will become a benefit for clients of all ages and may be reimbursed to physician assistant, nurse practitioner, clinical nurse specialist, physician, and nephrology (hemodialysis, renal dialysis) providers for services rendered in the office setting and to hospital, nephrology (hemodialysis, renal dialysis), and renal dialysis facility providers for services rendered in the outpatient hospital setting.

All services except for ultrafiltration (revenue code B-881) will be restricted to the following diagnosis codes:

Diagnosis Codes
N170	N171	N172	N178	N179	N181
N182	N1830	N1831	N1832	N184	N185
N186	N189	N990	T795XXA	T795XXD	T795XXS

Reimbursement Methodology Consolidated Billing

The following physician services will be a benefit for physician supervision of end-stage renal disease (ESRD) dialysis services and will be restricted to chronic kidney disease stage 5 (diagnosis code N185) and ESRD (diagnosis code N186):

Physician Services for ESRD Procedure Codes
90951	90952	90953	90954	90955	90956	90957
90958	90959	90960	90961	90962	90963	90964
90965	90967	90968	90969	90970

Physician Services for Hemodialysis or Other Dialysis Procedures Procedure Codes
90935	90937	90945	90947

Unscheduled or emergency dialysis procedure code G0257 will only be payable to clients with chronic kidney disease stage 5 (diagnosis code N185) and ESRD (diagnosis code N186).

Renal Dialysis Facilities – Consolidated Billing

Renal dialysis facilities are reimbursed according to their composite rates, which are based on the Centers for Medicare & Medicaid Services (CMS) calculations and the Texas Medicaid reimbursement methodology (TMRM).

The facility bills an amount that represents the charge for the facility’s service to the dialysis client. The facility’s charge must not include the charge for the physician’s routine supervision.

A revenue code (B-821, B-831, B-841, or B-851) must be billed for the dialysis facility to receive the composite rate payment.

Maintenance Hemodialysis

ESRD facilities with dialysis treatments are paid for up to three treatments per week. ESRD facilities that treat patients at home, regardless of modality, receive payment for three hemodialysis equivalent treatments per week.

Maintenance Intermittent Peritoneal Dialysis (IPD)

Maintenance IPD is usually performed in sessions of 10 to 12 hours duration, three times per week. However, it is sometimes performed in fewer sessions or longer duration.

Maintenance CAPD and CCPD

For clients undergoing continuous ambulatory peritoneal dialysis (CAPD) or continuous cycling peritoneal dialysis (CCPD) in the home setting, the number of days of peritoneal dialysis treatments will be limited to 14 sessions within 31 days, regardless of any dialysate exchanges performed each day.

A combination of hemodialysis, IPD, CAPD, or CCPD dialysis treatments will be limited to 14 sessions within 31 days for any provider. If more than 14 sessions are needed, the provider must submit documentation of medical necessity with the claim. Documentation can include but is not limited to medical records, physician’s notes, and lab results. Client records must clearly show why extra sessions are medically required.

The composite rate includes all the following necessary equipment, supplies, and services procedure codes for the client receiving dialysis either in the home or facility setting:

Procedure Codes – DME ESRD Supply
36000	36430	36591	36593	49421	71045
71046	71047	71048	93005	93040	93041
A4215	A4216	A4217	A4218	A4244	A4245
A4246	A4247	A4248	A4450	A4452	A4651
A4652	A4653	A4657	A4660	A4663	A4670
A4671	A4672	A4673	A4674	A4680	A4690
A4706	A4707	A4708	A4709	A4714	A4719
A4720	A4721	A4722	A4723	A4724	A4725
A4726	A4728	A4730	A4736	A4737	A4740
A4750	A4755	A4760	A4765	A4766	A4770
A4771	A4772	A4773	A4774	A4802	A4860
A4870	A4890	A4911	A4913	A4918	A4927
A4928	A4929	A4930	A4931	A4932	A6204
A6215	A6216	A6250	A6260	A6402	E0210
E0424	E0431	E0434	E0439	E0440	E0441
E0442	E0443	E0444	E0447	E1500	E1510
E1520	E1530	E1540	E1550	E1560	E1570
E1575	E1580	E1590	E1592	E1594	E1600
E1610	E1615	E1620	E1625	E1630	E1632
E1634	E1635	E1636	E1637	E1639	E1699

The Tablo hemodialysis system rental procedure code E1629 billed with revenue code B-821 is excluded from the composite rate and will be paid separately for clients receiving services in the home setting.

Laboratory testing may be processed in the renal dialysis facility or by an outside laboratory. Charges for routine laboratory tests listed in the table below are included in the facility’s composite rate and billed to Texas Medicaid, regardless of where the tests were processed.

Routine laboratory testing that is processed by an outside laboratory will be billed to the facility and billed by the renal dialysis facility unless the tests are inclusive.

The following procedure codes will be denied if they are billed with revenue codes B-821, B-829, B-831, B-839, B-841, B-849, B-851, B-859, or B-880, or procedure code G0257.

Procedure Codes – Labs Subject to ESRD Consolidated Billing
80047	80048	80051	80053	80069	80076
81050	82040	82108	82306	82310	82330
82374	82379	82435	82565	82570	82575
80607	82610	82652	82668	82728	82746
82947	83540	83550	83615	83735	83970
84075	84100	84132	84134	84155	84157
84295	84450	84466	84520	84540	84545
85004	85014	85018	85025	85027	85041
85044	85045	85046	85048	85345	85347
85610	86704	86705	86706	87040	87070
87071	87073	87075	87076	87077	87081
87340	87341	87467	G0306	G0307	G0499

The following procedure codes use the QW modifier: 80047, 80048, 80051, 80053, 80069, 82040, 82310, 82330, 82374, 82435, 82565, 82570, 84075, 84132, 84155, 84295, 84520, 85014, 85018, and 85025.

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

Procedure Codes – Drugs Subject to ESRD Consolidated Billing
J0360	J0604	J0606	J0620	J0630	J0636
J0670	J0878	J0884	J0887	J0892	J0895
J0899	J0945	J1160	J1200	J1205	J1240
J1265	J1270	J1443	J1444	J1445	J1642
J1643	J1644	J1720	J1740	J1750	J1800
J1940	J1945	J1955	J2001	J2150	J2360
J2430	J2501	J2720	J2795	J2993	J2997
J3265	J3364	J3365	J3370	J3410	J3420
J3480	J3489	J7030	J7040	J7042	J7050
J7060	J7070	J7120	J7131	Q0163	Q5105

The procedure codes above will be denied if they are billed with revenue codes B-821, B-829, B-831, B-839, B-841, B-849, B-851, B-859, or B-880, or procedure code G0257.

The following drugs used for the treatment of ESRD are excluded from the composite rate and will be paid separately:

Procedure Codes – Drugs Not Subject to ESRD Consolidated Billing
J0882	J1439	J1756	J2916	Q4081

Other drugs and biologicals supplied by an ESRD facility that are not used for the treatment of ESRD may be billed separately.

The ordering physician must maintain documentation supporting medical necessity in the client’s medical record.

Training for Hemodialysis, IPD, CCPD, and CAPD

Most self-dialysis training for hemodialysis, IPD, CCPD, and CAPD is provided in an outpatient setting. Dialysis training provided in an inpatient setting will be reimbursed at the same rate as the facility’s outpatient training rate.

Dialysis training is limited to 18 sessions per lifetime.

Ultrafiltration

A separate ultrafiltration treatment to remove excess fluid may be reimbursed.

Ultrafiltration is performed on a day other than the day of a dialysis treatment. The dialysis facility must document in the client’s medical record why the ultrafiltration could not have been performed at the time of the dialysis treatment. Ultrafiltration performed on the same day as the dialysis treatment will not be separately reimbursed.

Ultrafiltration may be reimbursed using revenue code B-881 for up to a maximum of three times per week. Providers can request additional ultrafiltration procedures if they provide documentation that state any of the following:

• Fluid overload (diagnosis code E8771) or diagnosis codes E8770, E8779, or E878 submitted on the claim
• Clotted intravenous (IV) access
• Chronic renal disease (CRD) treatment performed on another day due to a holiday
• Other reasons why extra ultrafiltration is necessary

Nonroutine Outpatient ESRD

The following services may be provided in conjunction with physician supervision of outpatient ESRD dialysis but are considered nonroutine and may be billed separately:

• The declotting of shunts when performed by a physician.
• Physician services that are provided to inpatients. If a client is hospitalized during a calendar month of ESRD-related services before a complete assessment is performed, or the client receives one or more face-to-face assessments, the timing of the inpatient admission prevents the client from receiving a complete assessment. The physician should bill procedure code 90967, 90968, 90969, or 90970 for each date of outpatient supervision and bill the appropriate hospital evaluation and management procedure code for individual services provided on the hospitalized days. If a client has a complete assessment during a month in which the client is hospitalized, procedure code 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, or 90962 must be reported for the month of supervision, determined by the number of face-to-face physician visits with the client during the month and the client’s age. The appropriate inpatient evaluation and management procedure codes should 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 monthly capitated payment (MCP). The physician must bill procedure code 90967, 90968, 90969 or 90970 for each date that supervision is provided. The physician may not bill for the days that the client is dialyzed elsewhere.
• Physician services beyond those that are related to the treatment of the client’s renal condition that causes the number of physician-client contacts to increase. Physicians may bill on a fee-for-service basis if documentation is submitted with the claim that the illness is not related to the renal condition and that additional visits are required.

All physician, renal dialysis center, and medical supplier supporting documentation is subject to retrospective review.

Inpatient services provided to hospitalized clients for whom the physician has agreed to bill monthly may be reimbursed in one of the following three ways:

• The physician may elect to continue monthly billing, in which case they may not bill for individual services provided to hospitalized clients.
• The physician may reduce the monthly bill by one-thirtieth for each day of hospitalization and charge fees for individual services provided on the hospitalized days.
• The physician may bill for inpatient dialysis services using the inpatient dialysis procedure codes. The physician must be present and involved with the clients during the dialysis procedure.

Clients may receive dialysis at an outpatient facility other than their usual dialysis setting, even if their physician bills for monthly dialysis coordination. The physician must reduce the monthly billed amount by one-thirtieth for each day the client is dialyzed elsewhere.

Payment is made for physician training services in addition to the MCP for physician supervision rendered to maintenance facility clients.

Provider Type Updates

Procedure codes E1510 and E1530 will be benefits for clients of all genders.

Procedure code 71045 may be reimbursed as follows:

• The total component may be reimbursed:
  • To nephrology (hemodialysis, renal dialysis) providers in the office setting and to nephrology (hemodialysis, renal dialysis) and renal dialysis providers for services rendered in the outpatient hospital setting.
• The technical component may be reimbursed:
  • To physician assistant, nurse practitioner, clinical nurse specialist, and radiation therapy center providers for services rendered in the office setting.

Procedure code 71046 may be reimbursed as follows:

• The total component may be reimbursed:
  • To nephrology (hemodialysis, renal dialysis) providers in the office setting and to nephrology (hemodialysis, renal dialysis) and renal dialysis providers for services rendered in the outpatient hospital setting.

Procedure codes 71047 and 71048 may be reimbursed as follows:

• The total component may be reimbursed:
  • To physician assistant, nurse practitioner, clinical nurse specialist, and nephrology (hemodialysis, renal dialysis) providers for services rendered in the office setting.
  • To radiation therapy center, nephrology, and renal dialysis center providers for services rendered in the outpatient hospital setting.

The following procedure codes will be updated with provider type and places of service:

Procedure Code	Provider Type and Place of Service
80047, 80048, 80051, 80053, 80069, 80076	Physician assistant, nurse practitioner, clinical nurse specialist, and nephrology (hemodialysis, renal dialysis) providers for services rendered in the office setting
81050	Physician assistant, nurse practitioner, clinical nurse specialist, and nephrology (hemodialysis, renal dialysis) providers in the office setting and nephrology (hemodialysis, renal dialysis) and renal dialysis providers for services rendered in the outpatient hospital setting
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, 84157, 84295, 84450, 84466, 84520, 84540, 84545, 85004, 85014, 85018, 85025, 85027, 85041, 85044, 85045, 85046, 85048, 85345, 85347, 85610, 87040, 87070, 87071, 87073, 87075, 87076, 87077, 87081, 87340, 87341, 87467, 93040, G0306, G0307	Physician assistant, nurse practitioner, clinical nurse specialist, and nephrology (hemodialysis, renal dialysis) and renal dialysis providers in the office setting and nephrology (hemodialysis, renal dialysis) and renal dialysis providers for services rendered in the outpatient hospital setting
85049	Physician assistant, nurse practitioner, clinical nurse specialist providers for services rendered in the office setting
90963	Physician providers for services rendered in the office setting
93005, 93041	Nephrology (hemodialysis, renal dialysis) and renal dialysis providers for services rendered in the outpatient hospital setting
E0210-DME Purchase New	Medical supplier (DME), medical supply company, and custom DME providers for services rendered in the office setting and medical supply company providers for services rendered in the home setting
J0604, J0606, J0636, J0892, J0895, J0899, J1205, J1270, J1439, J1443, J1444, J1445, J1740, J1945, J2001, J7131	Nephrology (hemodialysis, renal dialysis) providers for services rendered in the office setting and nephrology (hemodialysis, renal dialysis) and renal dialysis providers in the outpatient hospital setting
J0878	Nephrology (hemodialysis, renal dialysis) and renal dialysis providers for services rendered in the office setting
J0882, J0887	Nephrology (hemodialysis, renal dialysis) providers for services rendered in the office setting
J0945	Physician assistant, nurse practitioner, clinical nurse specialist, and nephrology (hemodialysis, renal dialysis) for services rendered in the office setting, medical supplier (DME) providers for services rendered in the home setting, and hospital, nephrology, (hemodialysis, renal dialysis) and renal dialysis providers for services rendered in the outpatient hospital setting
J0620, J0360, J0670, J1200, J1240, J1720, J1750, J1800, J1940, J1955, J2360, J2430, J2501, J2795, J2993, J2997, J3265, J3364, J3365, J3370, J3410, J3480, J3489	Nephrology (hemodialysis, renal dialysis) for services rendered in the office setting, medical supplier (DME) providers in the home setting, and nephrology (hemodialysis, renal dialysis) and renal dialysis providers for services rendered in the outpatient hospital setting
J1265	Nephrology (hemodialysis, renal dialysis) for services rendered in the office setting, medical supplier (DME) providers in the home setting, and physician assistant, nurse practitioner, clinical nurse specialist, and physician providers in the outpatient hospital setting
J2916	Nephrology (hemodialysis, renal dialysis) for services rendered in the office setting, medical supplier (DME) providers in the home setting and nephrology (hemodialysis, renal dialysis) for services rendered in the outpatient setting
Q4081	Nephrology (hemodialysis, renal dialysis) for services rendered in the office setting and nephrology (hemodialysis, renal dialysis) and renal dialysis providers for services rendered in the inpatient hospital setting

Procedure code J1756 will no longer be diagnosis restricted and may be reimbursed to nephrology (hemodialysis, renal dialysis) for services rendered in the office setting or to medical supplier (DME) providers in the home setting.

Procedure codes 86704, 86705, and 86706 will no longer be reimbursed:

• To physician group, independent laboratory/privately owned laboratory, optometrist, podiatrist, certified nurse midwife, registered nurse, licensed midwife, radiation therapy center, and hospital providers for services rendered in the office setting.
• To independent laboratory/privately owned laboratory, radiation therapy center, and rural health clinic (hospital-based) providers for services rendered in the outpatient hospital setting.
• To radiation therapy center, hospital, nephrology (hemodialysis, renal dialysis), and rural health clinic (hospital-based) providers for services rendered in the independent laboratory setting.

Procedure codes J1160, J1642, J1643, J1644, J2150, and J2720 will no longer be reimbursed to hospital providers for services rendered in the office or home setting.

The following procedure codes will no longer be benefits:

• Revenue codes B-845 and B-855
• Monthly DME rental procedure code E0210
• DME purchase procedure codes E1510 and E1635
• Procedure codes J0630 and J3365

For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.