From the Field: Monthly Capitation Payment Breakdown

By Sarah Tolson

In recent months, I’ve received an influx of questions from readers about the Medicare Monthly Capitation Payment (MCP). Many of these questions are related to the increasing utilization of physician assistants (PAs) and nurse practitioners (NPs), in addition to questions about CMS regulation changes at the beginning of the year that allow free-standing dialysis facilities and patient homes to be acceptable originating sites for end-stage renal disease (ESRD)-related telehealth services. In this issue, we will explore these areas as well as the MCP fundamentals.

What is the MCP?

A Monthly Capitation Payment (MCP) is a payment made to physicians for most dialysis-related physician services furnished to Medicare ESRD patients on a monthly basis. Medicare reimbursement for an in-center ESRD patient who receives four visits is the same as the reimbursement for supervising a patient that dialyzes at home. Reimbursement of the MCP for in-center patients that receive three or fewer visits can vary depending on the number of visits provided during the calendar month. Reimbursement also varies based on the age of the ESRD patient.

What services are included in the MCP and what physician services can be billed separately from the MCP?

The Medicare claims processing manual states that the MCP is reported once per month for services performed in an outpatient setting that are related to the patient’s ESRD. These outpatient services include assessment of diet and nutrition needs, appropriate mode of dialysis, access type, transplant qualification, dialysis prescription, anemia management, bone and mineral metabolism, hypertension, review of dialysis adequacy, physical assessments, interpretation of various tests, coordination of care with other medical professionals, and any other ESRD-related outpatient service as outlined in CMS Pub. 100-04, Ch 8.

Services excluded from MCP include interpretation of tests that have a professional component  (electrocardiograms, 24-hour blood pressure monitor, biopsies, etc.), surgical services such as dialysis catheter placement or repair, thrombectomy of clotted cannula or bone marrow biopsy, patient training for home dialysis, covered physician services furnished to hospital inpatients, and non-renal related physician’s services—as long as they are not incidental to services furnished during a dialysis session or office visit necessitated by the renal condition.

Can telehealth visits replace some of the face-to-face visits in the MCP?

Effective the first of this year, CMS recognizes free-standing dialysis facilities and patient homes as eligible originating sites for telehealth services. This policy change has the potential to greatly benefit home dialysis patients and nephrologists. After a patient’s first three months on home dialysis, Medicare allows for a monthly comprehensive telehealth visit twice per quarter. Some considerations for the use of telehealth in a nephrology practice include the availability of internet connectivity in the patient’s home, ability to clearly visualize the patient’s access, and whether there are options to help the patient with sight or hearing impairments as well as equipment to capture the patient’s vital signs remotely.

Who should bill for the MCP in a nephrology practice where NPs and PAs provide some of the monthly visits for a patient?

Medicare allows some flexibility to physicians and nonphysician practitioners providing care to ESRD patients. Physicians, clinical nurse specialists, nurse practitioners, and physicians’ assistants are acceptable provider types to provide face-to-face visits. The MCP physician may use other practitioners or physicians to provide visits during the month without being present as long as the other practitioner is a partner, employee of the same group practice, or employee of the MCP physician.

The billing physician, according to the Medicare claims processing manual, should be the physician who provides the complete assessment, establishes the patient’s plan of care, and provides ongoing management. In the event the practitioner that performs the complete assessment and establishes the plan of care is a nonphysician practitioner, the MCP service should be billed under the PIN of the non-physician practitioner.

Sarah Tolson is the director of operations for Sceptre Management Solutions, Inc., a company specializing in billing for outpatient ESRD facilities, nephrology practices, and vascular access. Your questions are welcome and she can be reached at stolson@sceptremanagement.com, 801.775.8010, or via Sceptre’s website, www.sceptremanagement.com.