Alliance Health Dialysis Coverage Policy Update

Coverage Criteria for Dialysis Services

Covered Services

Covered when ALL of the following are met:

General coverage: Dialysis services (hemodialysis, peritoneal dialysis, self-dialysis) are covered when provided by a Medicaid & Medicare certified ESRD hospital-based or freestanding facility for beneficiaries requiring dialysis services.

Includes routine labs, drugs, equipment and support services under a composite rate for ESRD and AKI.

Dialysis modalities: Hemodialysis, CAPD, CCPD, home dialysis (when beneficiary and/or caregiver have completed training), and self-dialysis are acceptable treatments.

Hemodialysis is typically 3–5 hour sessions, usually 3 times per week; CCPD sessions take about 10–12 hours at night. Home dialysis is not covered for beneficiaries with AKI.

Payment methodology: A composite rate bundles routine laboratory services, parenteral drugs, medical equipment and supplies, and support services furnished by certified ESRD facilities; the same payment methodology applies for beneficiaries with ESRD and AKI.

Both hospital-based and freestanding ESRD facilities are reimbursed for AKI services.

General Criteria Covered

Covered when ALL of the following are met:

General coverage criteria: a. The procedure, product, or service is individualized, specific, and consistent with the beneficiary's symptoms or confirmed diagnosis and not in excess of the beneficiary's needs; b. The procedure, product, or service can be safely furnished and no equally effective and more conservative or less costly treatment is available statewide; c. The procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.

Providers must document medical necessity and follow general medical necessity standards.

Specific Criteria Covered

Specific dialysis coverage and reimbursement rules:

Composite rate inclusion: All dialysis-related laboratory services and parenteral drugs listed on NC Medicaid's Composite list are included in the composite rate; specific CPT and HCPCS codes are provided in Attachment A and C.

The facility may contract with an independent laboratory but the facility is responsible to reimburse the contracted lab; NC Medicaid will not directly reimburse independent labs for composite items.

Dialysis treatments covered: CAPD and CCPD are billed per date of service (not per treatment); hemodialysis is covered up to three times weekly and cannot exceed one dialysis treatment per date of service; dialysis for AKI is covered during the monthly billing cycle with only one payment allowed for one treatment per day across settings; additional payment for uncompleted or partial treatments may be allowed.

Providers shall document the first date of the ongoing dialysis treatment on each claim and bill dialysis-related services once per calendar month using the last day of the month as the date of service (or date of death/last seen if earlier).

Additional reimbursement: In addition to the composite rate, ESRD facilities may receive reimbursement for: designated laboratory services provided for non-dialysis reasons (with a non-renal primary diagnosis), supplies and processing fees for blood administration, drugs not included in the composite list, certain vaccines administered during dialysis, physician Monthly Capitation Payment (MCP) or Daily Capitation Payments in defined situations, and training/retraining services.

Home dialysis is performed by a trained ESRD beneficiary or private caregiver per 42 CFR §494.100(a). Home dialysis is not covered for beneficiaries diagnosed with Acute Kidney Injury (AKI) because AKI patients require close medical supervision and care in an appropriate facility setting.

Medicaid does not cover services when the beneficiary fails to meet eligibility in Section 2.0 or the clinical criteria in Section 3.0, when the service duplicates another provider's service, or when the service is experimental, investigational, or part of a clinical trial.

Specific dialysis services not covered include items already included in monthly capitation (office/home visits, consults, care plan oversight), access maintenance performed by ESRD facility staff, take-home drugs and supplies, specimen collection fees, transportation, routine medical supply charges (including syringes), private caregiver costs outside allowed training, and capitation payment for any month in which a training code is billed. Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis or dialysis-related services under this policy.

All dialysis-related laboratory services listed on NC Medicaid's Composite list are included in the composite rate and must not be itemized on the provider's claim. Itemizing any composite-listed lab CPT will result in denial of that line item with the explanation: 'Routine labs included in the dialysis fees.'

For telehealth claims, providers must append Modifier GT to CPT or HCPCS codes to indicate interactive audio-visual service. Modifier GT is not appropriate for virtual communications or remote patient monitoring; follow the applicable modifier guidance for non-telehealth and telehealth claims.

Procedures, products, or services that do not meet Medicaid eligibility or the policy's listed criteria, that duplicate another provider's service, or that are experimental, investigational, or part of a clinical trial are not covered and should not be billed to Medicaid.

Coding, CPT/HCPCS and Composite Lists

Claims and coding attachments referenced (ICD-10, CPT, Modifiers, Revenue)mixed

No codes listed

Covered CPT/HCPCS codes (refer to attachments)mixedCovered

See Attachment A, C

Specific CPT and HCPCS codes for composite dialysis services, dialysis-related labs, parenteral drugs, physician services, training/retraining, and other listed items are provided in Attachment A and C.

Laboratory CPTs included in composite rateCPTCovered

80047	Laboratory CPT included in composite rate
80048	Laboratory CPT included in composite rate
80051	Laboratory CPT included in composite rate
80053	Laboratory CPT included in composite rate
80061	Laboratory CPT included in composite rate
80069	Laboratory CPT included in composite rate
81000	Laboratory CPT included in composite rate
82374	Laboratory CPT included in composite rate
82435	Laboratory CPT included in composite rate
82436	Laboratory CPT included in composite rate

1–10 of 40

1/4

Drugs included in composite rate (HCPCS)HCPCSCovered

J0171	Drug included in composite rate (HCPCS listed associations)
J1200	HCPCS associated with listed drugs
J1800	HCPCS associated with listed drugs
J1940	HCPCS associated with listed drugs
J2150	HCPCS associated with listed drugs
J2370	HCPCS associated with listed drugs
J2690	HCPCS associated with listed drugs
J2720	HCPCS associated with listed drugs
J2760	HCPCS associated with listed drugs
J7042	HCPCS associated with listed drugs

1–10 of 19

1/2

Vaccines allowed to be billed separatelyCPTCovered

90471	Vaccine administration (separate billable vaccine service)
90472	Vaccine administration (separate billable vaccine service)
90473	Vaccine administration (separate billable vaccine service)
90474	Vaccine administration (separate billable vaccine service)
90670	Vaccine code allowed to be billed separately

Miscellaneous labs and procedures billable separately when medically necessaryCPTCovered

82108	Misc lab that may be billed separately; frequency: once every three months
82728	Misc lab that may be billed separately; frequency: once every three months
85048	Misc lab that may be billed separately; frequency: once every three months
93000	Misc procedure that may be billed separately; frequency: once every three months
93005	Misc procedure that may be billed separately; frequency: once every three months
93010	Misc procedure that may be billed separately; frequency: once every three months
93040	Misc procedure that may be billed separately; frequency: once every three months
93041	Misc procedure that may be billed separately; frequency: once every three months
93042	Misc procedure that may be billed separately; frequency: once every three months
78300	Misc procedure that may be billed separately; frequency: once per year

1–10 of 12

1/2

Capitation and self-dialysis training codesCPTCovered

90951	Monthly capitation code for full month of physician reimbursements; telehealth eligible
90952	Monthly capitation code for full month of physician reimbursements; telehealth eligible
90953	Monthly capitation code for full month of physician reimbursements; telehealth eligible
90954	Monthly capitation code for full month of physician reimbursements; telehealth eligible
90955	Monthly capitation code for full month of physician reimbursements; telehealth eligible
90956	Monthly capitation code for full month of physician reimbursements; telehealth eligible
90957	Monthly capitation code for full month of physician reimbursements; telehealth eligible
90958	Monthly capitation code for full month of physician reimbursements; telehealth eligible
90967	Daily capitation code for partial month; telehealth eligible
90968	Daily capitation code for partial month; telehealth eligible

1–10 of 14

1/2

Condition codesmixed

Condition code 84

Dialysis for Acute Kidney Injury (AKI) — to be used for AKI services

Monthly Capitation CodesCPTCovered

90951	Monthly capitation code; Telehealth Eligible Services = Yes
90952	Monthly capitation code; Telehealth Eligible Services = Yes
90953	Monthly capitation code; Telehealth Eligible Services = Yes
90954	Monthly capitation code; Telehealth Eligible Services = Yes
90955	Monthly capitation code; Telehealth Eligible Services = Yes
90956	Monthly capitation code; Telehealth Eligible Services = Yes
90957	Monthly capitation code; Telehealth Eligible Services = Yes
90958	Monthly capitation code; Telehealth Eligible Services = Yes

Monthly Capitation Associated CPTsCPT

90959	Associated CPT for 90951 (as listed)
90960	Associated CPT for 90952 (as listed)
90961	Associated CPT for 90953 (as listed)
90962	Associated CPT for 90954 (as listed)
90963	Associated CPT for 90955 (as listed)
90964	Associated CPT for 90956 (as listed)
90965	Associated CPT for 90957 (as listed)
90966	Associated CPT for 90958 (as listed)

Daily Capitation CodesCPTCovered

90967	Daily capitation code for partial month; Telehealth Eligible Services = Yes
90968	Daily capitation code for partial month; Telehealth Eligible Services = Yes
90969	Daily capitation code for partial month; Telehealth Eligible Services = Yes
90970	Daily capitation code for partial month; Telehealth Eligible Services = Yes

Self-dialysis Training CodesCPTCovered

90989	Self-dialysis training session code; Telehealth Eligible Services = Yes; reimbursement for completed course allowed once per beneficiary lifetime
90993	Self-dialysis training session code; Telehealth Eligible Services = Yes; training sessions limited to 25 per beneficiary lifetime

Typical CCPD session duration

Typical CCPD session duration10-12 hours per night (overnight cycler use)

Hemodialysis frequency

Hemodialysis frequency (routine)Up to three times weekly (usually 3–5 hour sessions)

Per-date-of-service limitCannot exceed more than one dialysis treatment per date of service

Provider Responsibilities, Billing and Documentation

Documentation Required

Verify Medicaid Eligibility

An eligible beneficiary must be enrolled in the NC Medicaid Program. Providers shall verify each Medicaid beneficiary's eligibility at the time of each service. A beneficiary's eligibility category may restrict coverage for dialysis-related services and can render the beneficiary ineligible for the service.

Verify eligibility at each visit
Beneficiary may be ineligible due to Medicaid eligibility category

Denial Risk

Composite Labs Must Not Be Itemized

All dialysis-related laboratory services included on NC Medicaid's composite list must not be itemized on the provider's claim. Itemizing composite laboratory services will result in denial of the line item with the explanation: 'Routine labs included in the dialysis fees.'

Do not itemize composite-listed dialysis labs on claims

Clinical Background

Dialysis replaces kidney function for patients with chronic renal failure (ESRD) or for those with acute loss of kidney function (AKI). ESRD requires maintenance dialysis or transplant, while AKI is a sudden decline in renal function often managed in inpatient settings. The policy applies a composite payment methodology to routine dialysis services—bundling labs, drugs, supplies, and facility support—and specifies that certain items are excluded from separate billing. Clinical distinctions matter for coverage: ESRD beneficiaries may receive home or self-dialysis when trained, but home dialysis is not covered for AKI beneficiaries because AKI requires closer medical supervision and facility-based care.

Key Definitions

End-Stage Renal Disease (ESRD) definition

TermEnd-Stage Renal Disease (ESRD): Stage 5 chronic kidney disease requiring maintenance dialysis

GFR thresholdGFR < 15 mL/min/1.73 m2

Treatment statusIncludes kidney failure treated by dialysis or transplantation

Acute Kidney Injury (AKI) definition

TermAcute Kidney Injury (AKI): sudden episode of kidney failure or kidney damage causing build-up of waste products and fluid/electrolyte imbalance

Common settingsOften occurs in hospitalized patients, intensive care units, and older adults

OpenPayer

NC Medicaid Dialysis Services

Coverage Criteria for Dialysis Services

Coding, CPT/HCPCS and Composite Lists

Provider Responsibilities, Billing and Documentation

Clinical Background

Key Definitions