Medicare Faqs

In this section, you can find up-to-date info on paying for treatments, home equipment, training, travel, physician billing codes, and more.

National expert Beth Witten, MSW, ACSW, LSCSW wrote this.

According to experts, how many patients could do any type of home dialysis?

About 9% of those on dialysis are currently doing some type of home dialysis. In 1973, before Medicare started paying for dialysis, about 60% of patients did a home treatment.

Many people wonder what factors have contributed to the decline in home dialysis. One study found that U.S. nephrologists who'd been in practice for 11 or more years were significantly less likely to recommend PD1. The doctors who did were significantly more likely to refer patients who still had some residual kidney function and were:

  • Male (authors suggest female body image concerns or MD bias)
  • Compliant
  • Under 200 pounds
  • Not diabetic
  • Living with family

The authors expressed concern that if nephrologists keep using these factors to decide whom to refer, the growing rates of diabetes, obesity, malnutrition, patients living alone, and substance abuse could limit the future use of PD.

Another study of practicing nephrologists found that 47% believed PD and home HD were underused. In fact, they believed 11–14% of patients could do home HD and 26–39% of patients could do PD2. These nephrologists stated that these factors should be considered in modality choice (in order from most to least important):

  • Patient preference
  • Patient quality of life
  • Morbidity
  • Mortality
  • Clinic reimbursement
  • Physician reimbursement

References:

  1. Thamer M, et al. U.S. nephrologists' recommendation of dialysis modality: Results of a national survey. Am J Kidney Dis. 2000, 36(6):1155–65
  2. Mendelssohn DC, et al. What do American nephrologists think about dialysis modality selection? Am J Kidney Dis. 2001, 37(1):22–29
Why should I care if my dialysis clinic offers home dialysis?

Medicare has added a benefit for CKD education taught by certain providers (physicians, nurse practitioners, clinical nurse specialists, and physician assistants). One objective is to assure that patients with stage 4 CKD learn the treatment options for kidney failure. Also, the ESRD Conditions for Coverage require dialysis clinics to inform all patients about all of the options and where to get them—including options the clinic does not offer.

  • If a patient wants home dialysis and your clinic is not certified to train and support patients on home dialysis, he or she may choose to switch clinics—and even doctors.
  • Does your clinic admit patients who have little or no insurance? If so, starting them in home training (PD or home HD) before the 4th month of dialysis can improve clinic revenue. Why? Because Medicare can be backdated to the first day of the month dialysis starts when a patient starts training for a home treatment before the 4th month of dialysis. So, the clinic can bring in more revenue from Medicare for the first 120 days of treatment under the ESRD bundle's new onset adjustment. If patients don't have Medicare when they start dialysis and do not train for home dialysis, the clinic will only get the higher new onset payment for the number of days left after Medicare takes effect.
  • Offering home dialysis and arranging training around the patient's work schedule can help patients keep their jobs and higher-paying employer health plans. This coverage is primary for the first 30 months a patient is eligible for Medicare, and then secondary after that.
  • The more home patients a clinic has, the less the clinic has to spend to expand the existing clinic or to build another one.
  • As the number of home patients grows, the more cost effective a home program becomes.
  • A full-time RN can support about 20 home patients, depending on their acuity.
  • Empowering patients by teaching them to manage their illness and treatment may reduce patient-staff conflicts and improve patient and staff satisfaction.
  • Longer and more-frequent treatments may reduce patients' drug needs, which may save clinics money in a bundled reimbursement system.
  • USRDS data and studies of home dialysis show positive health outcomes that may lead to fewer and shorter hospital stays, which means higher clinic revenues.
What does Medicare require if a clinic wants to start a home training program?

Any clinic that wants to be paid for training and supporting home dialysis patients must be Medicare certified.

To start the process, fill out a CMS 855A form and send it to the Medicare contractor your clinic bills for in-center claims. The contractor will review the form and notify your State Survey Agency when the request is approved. Once the request is approved, your clinic will need to notify the State Survey Agency that you are ready for a survey. The State Survey Agency will add your clinic to its list. When the survey is done and any deficiencies corrected, the State Survey Agency will recommend that CMS add the service of home training and support services for HD and/or PD (depending upon what is requested/approved) to your clinic's certification.

To be certified, the clinic must meet all of the relevant requirements in the Conditions for Coverage. The Condition for Care at Home describes the requirements for training, staffing, equipment and supply maintenance, water and dialysate quality for home HD, medical records, emergency call, etc. That Condition refers to other areas in the Conditions for Coverage. In all areas, the clinic is expected to make sure that home patients receive at least the same level of care that in-center patients receive.

What does Medicare expect the clinic to teach patients who do home dialysis?

The dialysis regulations require the training RN to teach patients (and helpers, if needed) about these topics:

  • Kidney disease and how to manage it
  • How to use the supplies and equipment correctly to remove as many wastes and excess fluid as possible
  • How to manage anemia, using the drugs the doctor prescribes
  • How to detect, report, and manage problems that might occur, including machine and water treatment problems
  • How to reach help when needed
  • How to keep track, report, and record the patient's health status
  • How to handle medical and non-medical emergencies
  • How to avoid infections
  • How to get, store, and get rid of medical waste
How does a clinic bill for home dialysis?

The Medicare Claims Processing Manual, Chapter 8 on ESRD, explains billing for home dialysis including what the Medicare rate covers, condition codes, occurrence codes, value codes, and the following revenue codes:

  • 0821 Hemodialysis/Composite or other rate - HEMO/COMPOSITE
  • 0841 CAPD/Composite or other rate - CAPD/COMPOSITE
  • 0851 CCPD/Composite or other rate - CCPD/COMPOSITE

See Chapter 8 of the Medicare Claims Processing Manual §50 and §80 for billing the bundled composite rate for ESRD home dialysis services, including billing for training and re-training.

See Chapter 25 of the Medicare Claims Processing Manual for general instructions for completing the CMS-1450 (AKA UB-04 at present) or ANSI X12N formats.

What is the nephrologist payment for home training?

A nephrologist can bill Medicare $500 for supervising training of a home dialysis patient (PD or home HD), plus the monthly capitation payment (or MCP) for overseeing the care of any dialysis patient. The MCP is based on how many times (from one to four) a nephrologist (or nurse practitioner, clinical nurse specialist or physician assistant) sees a patient in a month. If a patient starts training but fails to complete it, the nephrologist can still charge $20 per training session completed. As a primary payer, Medicare Part B pays 80% of these charges after the patient meets the annual Part B deductible.

Nephrologists can receive the training supervision fee plus the MCP payment if a patient requires retraining due to a change in:

  • Home modality
  • Machine
  • Setting for dialysis
  • Dialysis partner

See Chapter 8 of the Medicare Claims Processing Manual, §150.

What billing codes should nephrologists use for home training and home dialysis patients?

Medicare pays a monthly capitation payment (MCP) to nephrologists and non-physician practitioners (nurse practitioners, clinical nurse specialists, and physician assistants) who follow home dialysis patients. The MCP amount is based on patient age. Management of patients who are on home dialysis for a full month is coded using the ESRD-related services for home dialysis patients using these codes:

CPT Code for MCP Long Descriptor
90963 ESRD-related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents
90964 ESRD-related services for home dialysis per full month, for patients 2–11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents
90965 ESRD-related services for home dialysis per full month, for patients 12–19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents
90966 ESRD-related services for home dialysis per full month, for patients 20 years of age or older
90967 ESRD-related services for dialysis less than a full month of service, per day for patients younger than 2 years of age
90968 ESRD-related services for dialysis less than a full month of service, per day for patients 2–11 years of age
90969 ESRD-related services for dialysis less than a full month of service, per day for patients 12–19 years of age
90970 ESRD-related services for dialysis less than a full month of service, per day for patients 20 years of age or older

These are the codes that nephrologists should use to bill for home dialysis training:

CPT Code for MCP 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 nephrologist reimbursement for training and retraining, see Chapter 8, §150 of the Medicare Claims Processing Manual.

If you have further questions about nephrologist billing for home dialysis, your Medicare Administrative Contractor would be a good resource.

How often are nephrologists required to see home dialysis patients to receive the MCP?

In most cases, the MCP physician or practitioner must have, and document in the patient's medical record, at least one face-to-face visit per month with a home patient to get the monthly capitation payment (MCP). Medicare Administrative Contractors may occasionally waive a monthly face-to-face visit for the home dialysis MCP on a case-by-case basis. This might happen, for example, when the nephrologist's notes indicate that he/she actively and adequately managed the care of the patient throughout the month.

See Chapter 8 of the Medicare Claims Processing Manual §140.1.1.

How should a nephrologist bill for a home patient who does in-center dialysis for part of a month?

If the same nephrologist manages the patient's care all month, he or she should bill the MCP rate for the home patient for the full month and not bill the rate for managing an in-center patient.

See Chapter 8 of the Medicare Claims Processing Manual §140.1.2.

How should a nephrologist bill for a patient that he/she manages for only part of a month?

The nephrologist should bill on a per-diem basis. This might occur with:

  • Home dialysis patients (less than full month)
  • Transient patients for less than full month
  • Partial month where there was one or more face-to-face visits without a complete patient assessment and the patient was hospitalized before a complete assessment was done, the patient died, or the patient had a transplant
  • Patients who permanently changed their MCP physician during the month

See Chapter 8 of the Medicare Claims Processing Manual §140.2.


Medicare has created a simple tool - The Out of Pocket Cost Estimator - to help you see how your coverage choices impact your costs. You can also compare your current costs with different coverage options.