Medicare Part B Payments for End-Stage Renal Disease Dialysis Services

Medicare Part B covers outpatient dialysis services for beneficiaries diagnosed with end-stage renal disease (ESRD). Prior Office of the Inspector (OIG) work identified inappropriate Medicare payments for ESRD services. Specifically, OIG identified unallowable Medicare payments for treatments not furnished or documented, services for which there was insufficient documentation to support medical necessity, and services that were not ordered by a physician or ordered by a physician that was not treating the patient. (Social Security Act §§ 1862(a)(l)(A) and 1833(e), 42 CFR §§ 410.32(a) and (d), 42 CFR §§ 410.12(a)(3), 424.5(a)(6), and 424.10).

Dialysis services, such as CPT codes 90935 and 90960-90963 (clinic ESRD) ESRD Monthly Capitation Payment (MCP) Coding and Frequency Limitations were listed on the Top 20 Types of Services with Insufficient Documentation Errors on the Comprehensive Error Rate Testing (CERT) report for 2017.

Missing supportive documentation may include daily treatment records, progress notes, etc. Documentation submitted supports CPT/HCPCS code change.

Additionally, prior OIG reviews identified claims that did not comply with Medicare consolidated billing requirements (the Act § 1881(b)(14), Medicare Claims Processing Manual, Pub. No. 100-04, Ch. 8 and Medicare Benefit Policy Manual, Pub. No. 100-02, Ch. 11) for Medicare Part B dialysis services provided to beneficiaries with ESRD.

Information concerning "ESRD Monthly Capitation Payment (MCP) Coding and Frequency Limitations" may be located on the Jurisdiction J Part B and Jurisdiction M Part B websites.


Last Updated: 01/29/2018