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Dialysis Services (ESRD) Coverage and Provider Requirements
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Rules governing coverage, reimbursement, provider enrollment, documentation, and professional services for outpatient dialysis and ESRD services under Mississippi Medicaid; applies to freestanding and hospital-based kidney dialysis centers and providers serving Mississippi Medicaid beneficiaries.
No material clinical or coverage changes in this revision.
Coverage Criteria for Dialysis and ESRD Services
Covered services and payment structure
Covered when services meet program requirements and are medically necessary as documented:
From Rule 1.2
From Rule 1.3
From Rule 1.4
Physician services are not payable under the dialysis facility’s provider number. Related physician services must be billed separately by the physician or qualified health care professional using the appropriate professional procedure codes that are excluded from the ESRD PPS rate. Facilities should not submit physician professional services on the facility’s billing number.
Evaluation and management services that are unrelated to dialysis care must not be performed and billed during the dialysis treatment session. Such non-dialysis E/M services must be provided at a separate encounter and reported separately by the furnishing provider; they cannot be bundled into or claimed as part of the dialysis session.
Dialysis services will not be reimbursed unless there are corresponding treatment notes documenting the service. Facilities must maintain treatment documentation for each dialysis encounter to support billing under the ESRD PPS rate; absence of such notes is a basis for nonpayment.
Coding, Payment, and Visit Frequency
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Provider Actions, Documentation, and Billing Rules
No prior authorization required
Prior authorization is not required for dialysis services.
Provider documentation responsibility
Providers must ensure auditable records and physician/qualified healthcare professional documentation are complete and maintained as required; include dates of service, monthly face-to-face evaluations, mode of dialysis and treatment plan, all treatments/medications/labs, and legible signature with credentials and date.
- Maintain auditable medical records that substantiate dialysis services.
- Physician/QHP documentation must include: dates of service; monthly face-to-face evaluation of current health status and appropriateness of treatment; mode of dialysis and treatment plan; all treatments, medications, biologicals, lab tests and other studies (included and excluded from ESRD PPS); legible signature with credentials and date.
- If more than one face-to-face visit is required in a month, documentation must support medical necessity; interdisciplinary team notes cannot substitute for physician/QHP face-to-face visit documentation.
Required clinical documentation elements
Providers must maintain auditable records substantiating dialysis services; physician or qualified healthcare professional entries must include dates of service, monthly face-to-face evaluations, mode of dialysis and treatment plan, all treatments/medications/labs (both included and excluded in the ESRD PPS), and a legible signature with credentials and date of entry.
- Dates of service
- Monthly face-to-face evaluation documenting current health status, provider findings, and treatment appropriateness
- Mode of dialysis and treatment plan
- All treatments, medications, biologicals, lab tests and other studies (included and excluded in the ESRD PPS)
- Legible signature of physician or qualified healthcare professional with credentials and date
Facility record requirements
Dialysis facility records must include dates of service; a current annual physician evaluation with pertinent labs/diagnostics; individualized treatment notes verifying each face-to-face physician visit; beneficiary assessment per 42 CFR § 494.80; written plan of care reviewed monthly by the interdisciplinary team; mode of dialysis and treatment plan; all treatments/medications/labs; and legible signatures with credentials and date.
- Dates of service
- Current annual evaluation (age/gender-appropriate history & physical) documented by a physician including pertinent labs/diagnostic procedures
- Individualized treatment notes verifying each face-to-face physician visit
- Beneficiary assessment in accordance with 42 CFR § 494.80
- Written plan of care prepared and reviewed monthly by interdisciplinary team
- Mode of dialysis and treatment plan
- All treatments, medications, biologicals, lab tests and other studies (included and excluded in the ESRD PPS)
- Legible signature of physician or healthcare professional with credentials and date
Missing treatment documentation will deny reimbursement
Dialysis services will not be reimbursed if there are no corresponding treatment notes; facilities must bill appropriate revenue codes and furnish necessary services and supplies under the bundled ESRD PPS rate.
- Ensure individualized treatment notes exist for each dialysis session to support reimbursement.
- Bill the appropriate revenue codes for the ESRD PPS rate and maintain documentation that substantiates provided services.
Background
End-stage renal disease (ESRD) requires ongoing renal replacement therapy and may be treated with facility-based or home modalities. Covered modalities include hemodialysis and peritoneal dialysis (including CAPD and CCPD). Dialysis care is provided under a bundled ESRD prospective payment system that covers supplies, equipment, drugs, laboratory services, and support services, and it requires coordinated interdisciplinary care with regular physician oversight. Physicians or qualified health care professionals must perform at least one face-to-face visit monthly and document medical necessity for any additional visits; documentation must be legible, signed and dated.
Definitions
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