Clarification of Payment for ESRD-Related Home Services Under the Monthly Capitation Payment


Physicians or practitioners are required to furnish at least one face-to-face patient visit per month for home dialysis Monthly Capitation Payment (MCP) services. To report these services you must use one of the CPT codes listed in the table below. 
 
CPT Code
Descriptor 
90963
Home Dialysis services per month, patients younger than 2

90964

Home Dialysis services per month, patients age 2–11

90965

Home Dialysis services per month, patients age 12–19

90966

Home Dialysis services per month, patients age 20+
  • Documentation by the MCP physician or practitioner should support at least one face-to-face encounter per month with the home dialysis patient and retained in the medical record 
  • Medicare contractors may waive the requirement for a monthly face-to-face visit for the home dialysis MCP service on a case by case basis
    • An example would be when the nephrologist's notes indicate that the physician actively and adequately managed the care of the home dialysis patient throughout the month
  • MCP physician or practitioner may use other Medicare certified physicians or qualified nonphysician practitioners to provide some of the visits during the month
  • Visits must be furnished face-to-face by a physician, clinical nurse specialist, nurse practitioner, or physician’s assistant
  • The MCP physician or practitioner does not have to be present when these other physicians or practitioners provide the visit(s)
  • The non-MCP physician or practitioner must be a partner, an employee of the same group practice, or an employee of the MCP physician or practitioner
  • The physician who provides the complete assessment, establishes the patient’s plan of care, and provides the ongoing management should bill for the MCP service when another physician is used to furnish some of the visits during the month
  • When the qualified nonphysician practitioner performs the complete assessment and establishes the plan of care, then the MCP service should be billed under the National Provider Identifier of the qualified non-physician practitioner (i.e., the clinical nurse specialist, nurse practitioner, or physician assistant)  

References

  • Pub. 100-02 (PDF, 468 KB), Chapter 11: End Stage Renal Disease
  • Pub. 100-04 (PDF, 1.86 MB), Chapter 8: Outpatient ESRD Hospital, Independent Facility, and Physician/ Supplier Claims
  • Pub. 100-04 (PDF, 569 KB), Chapter 16: Laboratory Services
  • MLN Matters article MM7520 (PDF, 94 KB): Clarification of Payment for ESRD-Related Services Under the Monthly Capitation Payment




Last Updated: 05/29/2020