Billing
When a person on Medicare needs dialysis, a clinic that is certified to provide home training and support can bill Medicare for a certain number of training sessions, depending on the type of treatment:
For home hemodialysis (082X), Medicare routinely pays for up to 25 training sessions.
For intermittent peritoneal dialysis (083X), Medicare limits payment to 3 times a week for up to 3 months.
For CAPD (084X), Medicare allows up to 15 training sessions.
For CCPD (085X), Medicare allows up to 15 training sessions.
Medicare may approve more training days if they are found to be medically necessary.
When Medicare WILL pay for retraining
After the initial training is over, changes in the home dialysis patient's circumstances may require retraining. If more training sessions are needed, there must be medical justification for Medicare to pay for them.
Medicare will pay for home dialysis retraining if—despite the patient's change in circumstances—home dialysis is still an appropriate treatment for the patient, and only in these cases:
The patient changes to a different type of home dialysis
The home dialysis equipment changes
The setting where the home dialysis occurs changes
The dialysis partner changes
The patient has a change in medical status that would not keep him or her from doing home dialysis—but would require additional training (examples in the Medicare Claims Processing Manual include memory loss due to stroke and physical impairment)
For more information, see Chapter 8, §50.8 in the Medicare Claims Processing Manual.
When Medicare WON'T Pay For Retraining
Medicare considers some services to be "retraining" and others to be expected home dialysis "support services." For example, if a PD patient develops peritonitis, the home training nurse may watch the patient perform PD connections/disconnections and catheter care using proper aseptic technique. Medicare considers this a home dialysis "support service"—not retraining. Other examples of home dialysis support services can be found under Chapter 11, §50.6 of the Medicare Benefit Policy Manual.
Billing Under The Prospective Payment System (PPS Or "Bundle")
There are many resources on the CMS site and in manuals to help you understand how to bill under the ESRD PPS or bundle. The PPS base rate pays for dialysis, supplies, and ESRD-related drugs and labs. There are patient-level adjustments, facility-level adjustments, and more.
One of the adjustments that Medicare will add is the “onset of dialysis” adjustment. When the person has or gets Medicare and the clinic is paid the "onset of dialysis" adjustment, there is no adjustment for home training or comorbidity. Medicare administrative contractors (MACs) that pay Medicare claims make the new onset adjustment for any of the first 120 dialysis days the patient has Medicare. The clock starts with the patient's first dialysis reported on the CMS 2728, the End Stage Renal Disease Medical Evidence Report. The adjustment is 151% of the ESRD PPS for that patient. The adjustment is only applied the first time a patient requires dialysis. It is not applied when a patient resumes dialysis after a failed transplant. During this first 120 days, the clinic cannot bill Medicare for home dialysis training. After that, the clinic should bill Medicare its usual PPS rate plus the training add-on for home training or if the patient needs retraining.
Example: Joe starts dialysis on December 15. He does not have Medicare at that time, but qualifies for it due to ESRD, not for any other reason:
If Joe signs up for Medicare and chooses in-center dialysis, his Medicare can start March 1. The clinic will get the onset of dialysis adjustment for any days Joe has Medicare during the first 120 days. December 15–February 28 is 75 days. The dialysis clinic will only get the onset adjustment for 45 days from March 1 through April 14. If Joe decides later to train for home dialysis, the facility can receive the training add-on for any training days. If he later needs retraining, the facility can receive payment for retraining then.
If Joe signs up for Medicare and starts a home training program for PD or home HD before March 1, Joe's Medicare can be backdated to December 1 (the first day of the month dialysis started). His clinic can receive the onset of dialysis adjustment for all 120 days starting December 15, the first day of his dialysis. While receiving the onset of dialysis adjustment, his facility cannot bill for training or retraining.
How To Bill Medicare For Training & Retraining
The billing codes a clinic should use for training and retraining are the same. Under the ESRD PPS, the reimbursement for a retraining day is the facility's base rate plus the training rate per day. If a patient changes treatment from hemodialysis to CCPD and requires 2 days of retraining on the PD cycler, the facility could bill for 2 days of retraining and should bill the PD daily rate for the other 5 days that week. Remember, the daily rate for PD is 3 times the hemodialysis rate divided by 7.
Physician Billing For Training & Retraining
Physicians can bill for training and retraining. The physician can bill $500 when a patient completes home training. If the patient does not complete training, the physician can bill $20 per training session up to $500. Here are the codes for physician billing for home dialysis training. This amount is subject to the deductible and 20% coinsurance.
| CPT Code | Long Descriptor |
|---|---|
| 90989 | Dialysis training, complete (bill with quantity 1; $500 allowed) |
| 90993 | Dialysis training, incomplete (enter # of sessions completed for quantity; based on 25 sessions at $20/session for $500) |
| 90993 | Retraining (for a different machine, different dialysis modality, change in setting, or change in dialysis partner; $20/session) |
For physician reimbursement for training and retraining, see Chapter 8, §150 of the Medicare Claims Processing Manual.
The Renal Physicians Association provides coding and billing seminars to help physicians bill correctly.
Key Points
Medicare can be backdated if a new dialysis patient chooses to train for home dialysis
A dialysis clinic is reimbursed more under the new onset of dialysis adjustment for all 120 days if a new dialysis patient has Original Medicare that whole time.
Although the dialysis clinic cannot bill Medicare for training or retraining days during the first 120 days of dialysis, the new onset of dialysis adjustment offsets the cost of training more than the training/retraining rate.
Home training that does not meet criteria for retraining is considered support services, and is not separately billable.
Medicare will reimburse physicians for training and retraining days.
Medicare manuals linked above, the CMS fact sheet on the CY 2021 ESRD PPS (updated yearly), and the Renal Physicians Association are resources to help you bill correctly.