PA Lookup

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.

Limits

Generally performed at or beyond 14 weeks gestation for genetic testing.

Other procedures performed on the same date of service as amniocentesis are covered if performed by the same provider and billed according to modifier rules.

Other related procedures during the amniocentesis follow-up period, and unrelated procedures during that follow-up period, are covered if performed by the provider who performed the amniocentesis. Amniocentesis is not covered when performed for sex determination without documented risk of an X-linked disorder, or for routine screening without the risk factors listed in the amniocentesis coverage subsection.

Exclusions

Ultrasound is not covered when:

-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:

-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:

-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP

Age Group Details

Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria

Place of Service

Inpatient, Outpatient, Physician’s Office.

How to Submit

N/A - No authorization is required

Resources

• 1E-4 Fetal Surveillance
• Records Management and Documentation Manual

Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.

Limits

Generally performed at or beyond 14 weeks gestation for genetic testing.

Other procedures performed on the same date of service as amniocentesis are covered if performed by the same provider and billed according to modifier rules.

Other related procedures during the amniocentesis follow-up period, and unrelated procedures during that follow-up period, are covered if performed by the provider who performed the amniocentesis. Amniocentesis is not covered when performed for sex determination without documented risk of an X-linked disorder, or for routine screening without the risk factors listed in the amniocentesis coverage subsection.

Exclusions

Ultrasound is not covered when:

-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:

-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:

-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP

Age Group Details

Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria

Place of Service

Inpatient, Outpatient, Physician’s Office.

How to Submit

N/A - No authorization is required

Resources

• 1E-4 Fetal Surveillance
• Records Management and Documentation Manual

Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.

Limits

Generally performed at or beyond 14 weeks gestation for genetic testing.

Other procedures performed on the same date of service as amniocentesis are covered if performed by the same provider and billed according to modifier rules.

Other related procedures during the amniocentesis follow-up period, and unrelated procedures during that follow-up period, are covered if performed by the provider who performed the amniocentesis. Amniocentesis is not covered when performed for sex determination without documented risk of an X-linked disorder, or for routine screening without the risk factors listed in the amniocentesis coverage subsection.

Exclusions

Ultrasound is not covered when:

-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:

-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:

-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP

Age Group Details

Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria

Place of Service

Inpatient, Outpatient, Physician’s Office.

How to Submit

N/A - No authorization is required

Resources

• 1E-4 Fetal Surveillance
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required