From the Field: New Frequency of Hemodialysis Local Coverage Determinations

Sarah Tolson

Effective March 1, 2019, several Medicare Administrative Contractors (MACs) began processing claims for hemodialysis treatments under new Local Coverage Determinations (LCDs). These LCDs underwent massive revisions after the proposed LCDs released in 2017 would have essentially eliminated reimbursement for more than three treatments per week because they were so strict.

Medicare, the largest payer in the United States dialysis industry, provides benefits and has built the current payment structure for dialysis around the three hemodialysis treatments per week model. There are a variety of scenarios where more frequent hemodialysis treatments are necessary for patients. Medicare has delegated the responsibility of determining the medical necessity of any treatments in excess of three per week to the Medicare Administrative Contractor.

Historically, there has been a fair amount of variation in the coverage policies held by each MAC for frequency of hemodialysis. Some MACs accepted six or seven different diagnoses as justification for additional dialysis sessions and the ICD-10 codes were published in their online policy, whereas other MACs had private lists of diagnoses that were not available for public viewing.

In late 2017, several MACs released identical draft LCDs regarding the frequency of hemodialysis that could have eliminated reimbursement for more than three treatments per week in all but the most extreme cases. Many groups with a stake in the renal community submitted comments to the MACs and the Secretary of Health and Human Services calling for changes to the final policy to allow reimbursement for all medically necessary additional treatments, not just those treatments related to acute conditions or acute onset.

Subsequently, all the MACs participated in a Contractor Advisory Committee meeting in which they reviewed the comments received by each contractor and incorporated some of the requested changes into their final LCDs. The resulting final LCDs contain 53 diagnoses ranging from Disorder of phosphorus metabolism, unspecified to Other specified complication of vascular prosthetic devices.

The LCDs are clear that coverage for additional sessions is available if conditions such as medical necessity, documentation that meets specific documentation guidelines, and appropriate use of billing modifiers are met. The documentation sources acceptable for supporting medical necessity have been expanded in the new LCD to include documents from recent hospital care, office visits, dialysis progress notes, or the nephrologist’s monthly capitation payment (MCP) visit notes. Additionally, the MACs released accompanying Hemodialysis Coding Guideline local coverage articles (LCAs) that define the billing and coding expectations that should be followed by dialysis billers. The new policies include a statement indicating the MACs will be monitoring the frequency of additional sessions and this may trigger a Medical Review or the addition of new diagnoses to the list of covered conditions.

What is not covered?

Three scenarios are given by the MACs to describe additional dialysis sessions that would not be covered.

  • Treatments not fully supported in the patient’s medical record
  • Planned inadequate or short dialysis
  • Treatments performed for convenience of patient or staff

Key Difference in the MACs LCDs

While preparing training materials for our staff on the new LCDs, I compared all the LCDs and LCAs side by side. For the most part, there are only a few minor differences in wording that have little impact on the meaning of the policies.

The LCAs for CGS, Palmetto, First Coast Service Options, Novitas, NGS, and Noridian contain three approaches of billing:

  1. The standard three treatments per week
  2. For dialysis sessions considered not to meet the medical justification for payment
  3. Medically justified dialysis sessions outside routine dialysis orders; to be used for medical conditions that may justify payments on an acute or short-term basis.

The hemodialysis coding guidelines released by WPS contain these same three approaches, but they include a fourth approach:

  • Medically appropriate and necessary dialysis exceeding 14 treatments per month and outlined in the Dialysis Orders. Some patients, due to chronic or long-term conditions, may require dialysis that exceeds the usually covered 14 treatments per month (three treatments per week).

I applaud WPS for this small addition to their coding guidelines and I hope the other contractors amend their LCAs to include the fourth approach in their LCAs as well.

Sources:

Contractor Name Jurisdiction LCD ID LCA ID
Wisconsin Physicians Service Insurance Corporation (WPS) J5, J8 L37537 A55703
CGS Administrators J15 L37575 A56159
Palmetto GBA JJ, JM L34575 A55354
First Coast Service Options JN L37564 A56262
Novitas Solutions, Inc. JH, JL L35014 A55723
National Government Services, Inc. (NGS) J6, JK L37475 A55672
Noridian Healthcare Solutions, LLC JF, JE L37504, L37502 A55676, A55675

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.