Frequency of Hemodialysis
This policy governs line-item billing, modifier use, and reimbursement rules for hemodialysis sessions for End Stage Renal Disease (ESRD) patients for Priority Health providers. It applies to facility and home dialysis billing (excludes training and other modalities).
No material clinical or coverage changes in this revision.
Coverage Criteria for Hemodialysis Frequency and Payment
Coverage criteria for hemodialysis frequency and payment
Payment is provided for routine dialysis up to three times weekly; additional sessions may be denied or considered based on documentation and modifier use.
Additional sessions beyond 3/week
- If additional sessions beyond 3/week are furnished without medical documentation supporting reasonable and necessary care, bill each additional session as 90999 CG. The CG modifier indicates the facility attests the additional treatment is not reasonable and necessary; each line billed with 90999 CG will be denied (CG use is retained for data analysis).
- If additional sessions beyond 3/week are furnished WITH medical documentation supporting that the extra sessions are reasonable and necessary, bill each additional session as 90999 KX. Lines billed as 90999 without a modifier will be paid as routine 3x/week; lines billed as 90999 KX will be considered for additional payment. Omission of the KX modifier will result in no additional payment for the line item.
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