PA Lookup

Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; rosette

Service Code

85461 (CPT) Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; rosette

Prior Authorization Required

No

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

How to Submit

N/A - No authorization is required

Hemolysin, acid

Service Code

85475 (CPT) Hemolysin, acid

Prior Authorization Required

No

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

How to Submit

N/A - No authorization is required

Heparin assay

Service Code

85520 (CPT) Heparin assay

Prior Authorization Required

No

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

How to Submit

N/A - No authorization is required

Heparin neutralization

Service Code

85525 (CPT) Heparin neutralization

Prior Authorization Required

No

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

How to Submit

N/A - No authorization is required

Heparin-protamine tolerance test

Service Code

85530 (CPT) Heparin-protamine tolerance test

Prior Authorization Required

No

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

How to Submit

N/A - No authorization is required

Iron stain, peripheral blood

Service Code

85536 (CPT) Iron stain, peripheral blood

Prior Authorization Required

No

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

How to Submit

N/A - No authorization is required

Leukocyte alkaline phosphatase with count

Service Code

85540 (CPT) Leukocyte alkaline phosphatase with count

Prior Authorization Required

No

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

How to Submit

N/A - No authorization is required

Mechanical fragility, RBC

Service Code

85547 (CPT) Mechanical fragility, RBC

Prior Authorization Required

No

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

How to Submit

N/A - No authorization is required

Muramidase

Service Code

85549 (CPT) Muramidase

Prior Authorization Required

No

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

How to Submit

N/A - No authorization is required

Osmotic fragility, RBC; unincubated

Service Code

85555 (CPT) Osmotic fragility, RBC; unincubated

Prior Authorization Required

No

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

How to Submit

N/A - No authorization is required

Osmotic fragility, RBC; incubated

Service Code

85557 (CPT) Osmotic fragility, RBC; incubated

Prior Authorization Required

No

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

How to Submit

N/A - No authorization is required

Platelet, aggregation (in vitro), each agent

Service Code

85576 (CPT) Platelet, aggregation (in vitro), each agent

Prior Authorization Required

No

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

How to Submit

N/A - No authorization is required

Phospholipid neutralization; platelet

Service Code

85597 (CPT) Phospholipid neutralization; platelet

Prior Authorization Required

No

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

How to Submit

N/A - No authorization is required

Phospholipid neutralization; hexagonal phospholipid

Service Code

85598 (CPT) Phospholipid neutralization; hexagonal phospholipid

Prior Authorization Required

No

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

How to Submit

N/A - No authorization is required

Dialysis Service

Service Code

85610 (CPT) Prothrombin time;

Prior Authorization Required

No

Telehealth Billable

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

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

Dialysis Service

Service Code

85611 (CPT) Prothrombin time; substitution, plasma fractions, each