PA Lookup
If you have questions about prior authorizations, please call:
Member and Recipient Service Line: 1-877-685-2415
Provider Support Service Line: 1-855-250-1539
1E-7 Family Planning Services
Family Planning Medicaid services are provided to an eligible Medicaid beneficiary of childbearing age to temporarily or permanently prevent or delay pregnancy. Medicaid Family Planning is designed to reduce unintended pregnancies and improve the well-being of children and families in North Carolina.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
Limits
- • For FP Medicaid beneficiaries, these services are limited to services described in the policy's covered family planning service set.
- • Outpatient hospital registration is limited for FP Medicaid; the only allowed outpatient registered surgical procedure or service is sterilization, IUD removal, or ultrasound for IUD-related complications including missing strings.
- • Ultrasound for IUD placement issues may be performed only during an annual assessment, comprehensive preventive medicine evaluation, or inter-periodic visit.
- • Telehealth claims, when allowed under the policy, must be filed with the provider's usual place of service and not place of service 02.
Exclusions
Ultrasound is not covered to verify IUD placement at the time of insertion. Ultrasounds are not intended for routine checking of placement after IUD insertion. FP Medicaid does not cover medical conditions unrelated to family planning or family planning-related services. For FP Medicaid, surgical procedures or hospital services requiring outpatient beneficiary registration are not covered other than medically necessary contraceptive device removal or sterilizations; the policy note also identifies ultrasound for an IUD complication or removal of an IUD as exceptions to hospital cost responsibility. Hospital emergency room or emergency department services, inpatient hospital services, and treatment for acute or chronic conditions discovered during screening are not covered under FP Medicaid.
Place of Service
Non-Telehealth Claims: a. Inpatient hospitals (not applicable for a FP Medicaid beneficiary) b. Outpatient hospital: For a FP Medicaid beneficiary, the only surgical procedure or service allowed requiring outpatient beneficiary registration is sterilization, IUD removal or ultrasound for IUD related complications including missing strings. c. Office: utilizing offices within places of service 11 (Office), 19 (Off Campus Outpatient) or 22 (On Campus Outpatient) d. Ambulatory Surgical Centers (applicable for a FP Medicaid beneficiary for a sterilization. Numeric POS code(s): 02-Telehealth Provided Other than in Patient's Home.
Additional Service Specifics
FP. GT applies only when the service is telehealth billable and delivered by interactive audio-video.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Resources
Dialysis Service
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.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
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.
Additional Service Specifics
Once every three months
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Resources
Electrocardiography, Echocardiography, and Intravascular Ultrasound
Electrocardiography is a procedure for recording electrical changes in the heart. The electrocardiogram (ECG or EKG) shows the series of waves that relate to the electrical impulses that occur during each beat of the heart. EKGs can evaluate and detect cardiac problems. Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart. Ultrasound waves rebound or echo off the heart to show the size, shape, and movement of the heart's valves and chambers. Each component is crucial to permit a full assessment of the heart and an accurate diagnosis of certain cardiovascular diseases.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Limits
Electrocardiogram A maximum of four, 12-lead EKGs is allowed per day.
Microvolt T-Wave Alternans Microvolt T-wave alternans is limited to once per day, regardless of whether it is performed while the beneficiary is at rest, during stress, or in a combination thereof.
The equipment used must be FDA approved for this indication and able to detect as little as 1 microvolt of T-wave alternans.
Holter Monitor The Holter monitor test is limited to one per 24-hour period.
Cardiac (Ambulatory) Event Monitors
- a. Event monitoring is limited to once per 30 days, regardless of the number of
transmissions.
- b. In order to bill any of the services that include 24-hour attended monitoring,
the provider must be available during the entire 24-hour period.
- c. The provider of the service must be capable of receiving and recording
transmissions, including receipt of the EKG signal as well as voice transmission relaying any associated symptoms.
- d. The person receiving the transmission must be a technician, nurse, or
physician trained in interpreting EKGs and clinical responses to abnormal EKGs.
- e. The transmission is reviewed for significant symptoms or EKG
abnormalities.
- f. Technicians should have immediate 24-hour access to a physician to review
transmitted data and make clinical decisions regarding the beneficiary.
- g. The provider must be capable of immediately notifying the beneficiary with
emergency instructions from the supervising or the attending physician, when appropriate.
- h. The emergency instructions for the beneficiary, as well as when and how to
contact available facilities to assist the beneficiary in case of emergencies, should be included by the attending physician in the referral for the monitoring Transthoracic Echocardiography TTE is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the beneficiary is transferred to a tertiary hospital for further specialized evaluation, the beneficiary has a change in clinical status, or guidance is needed during an interventional procedure.
Transesophageal Echocardiography TEE is limited to one per day for screening purposes.
Two intraoperative TEEs are allowed per day when performed during cardiac surgery as long as performed as part of the operative procedure. The preoperative (or pre-bypass) and post-operative (or post-bypass) components must be documented. Only the first intraoperative TEE can include the code for probe placement.
Doppler Echocardiography Doppler echocardiography procedures are add-on codes and must be listed separately in addition to the primary procedure. They are not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Intracardiac Echocardiography Intracardiac echocardiography is limited to one procedure per day for guidance of a catheter-based intervention. Intracardiac echocardiography is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Fetal Echocardiography Fetal Echocardiography is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the pregnant mother (fetus is the beneficiary) is transferred to a tertiary hospital for further specialized evaluation, the fetus has a change in clinical status, or guidance is needed during an interventional procedure.
Coronary Intravascular Ultrasound Coronary IVUS includes all transducer manipulations and repositioning within the specific vessel being examined, both before and after therapeutic intervention.
IVUS is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
One IVUS, initial vessel, is allowed per day. Three additional vessels are allowed per day, with the initial vessel IVUS.
Diagnosis Requirements
Specific covered indications for cardiovascular stress testing are: screening for coronary atherosclerosis and myocardial ischemia; follow-up after myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft to assess functional improvement during cardiac rehabilitation; follow-up of beneficiaries with palliated or unpalliated congenital heart disease; follow-up of pediatric and adult beneficiaries with dilated cardiomyopathy regardless of etiology; follow-up of pediatric and adult beneficiaries with hypertrophic cardiomyopathy; pre-operative assessment of beneficiaries being considered for valve replacement; and follow-up after valve replacement.
Place of Service
Inpatient, Outpatient, Office, Home, Intermediate care facility, Skilled nursing facility, and Independent Diagnostic Testing Facility
How to Submit
Please submit your request to Evolent
Resources
Dialysis Service
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.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
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.
Additional Service Specifics
Once every three months
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Resources
Electrocardiography, Echocardiography, and Intravascular Ultrasound
Electrocardiography is a procedure for recording electrical changes in the heart. The electrocardiogram (ECG or EKG) shows the series of waves that relate to the electrical impulses that occur during each beat of the heart. EKGs can evaluate and detect cardiac problems. Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart. Ultrasound waves rebound or echo off the heart to show the size, shape, and movement of the heart's valves and chambers. Each component is crucial to permit a full assessment of the heart and an accurate diagnosis of certain cardiovascular diseases.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Limits
Electrocardiogram A maximum of four, 12-lead EKGs is allowed per day.
Microvolt T-Wave Alternans Microvolt T-wave alternans is limited to once per day, regardless of whether it is performed while the beneficiary is at rest, during stress, or in a combination thereof.
The equipment used must be FDA approved for this indication and able to detect as little as 1 microvolt of T-wave alternans.
Holter Monitor The Holter monitor test is limited to one per 24-hour period.
Cardiac (Ambulatory) Event Monitors
- a. Event monitoring is limited to once per 30 days, regardless of the number of
transmissions.
- b. In order to bill any of the services that include 24-hour attended monitoring,
the provider must be available during the entire 24-hour period.
- c. The provider of the service must be capable of receiving and recording
transmissions, including receipt of the EKG signal as well as voice transmission relaying any associated symptoms.
- d. The person receiving the transmission must be a technician, nurse, or
physician trained in interpreting EKGs and clinical responses to abnormal EKGs.
- e. The transmission is reviewed for significant symptoms or EKG
abnormalities.
- f. Technicians should have immediate 24-hour access to a physician to review
transmitted data and make clinical decisions regarding the beneficiary.
- g. The provider must be capable of immediately notifying the beneficiary with
emergency instructions from the supervising or the attending physician, when appropriate.
- h. The emergency instructions for the beneficiary, as well as when and how to
contact available facilities to assist the beneficiary in case of emergencies, should be included by the attending physician in the referral for the monitoring Transthoracic Echocardiography TTE is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the beneficiary is transferred to a tertiary hospital for further specialized evaluation, the beneficiary has a change in clinical status, or guidance is needed during an interventional procedure.
Transesophageal Echocardiography TEE is limited to one per day for screening purposes.
Two intraoperative TEEs are allowed per day when performed during cardiac surgery as long as performed as part of the operative procedure. The preoperative (or pre-bypass) and post-operative (or post-bypass) components must be documented. Only the first intraoperative TEE can include the code for probe placement.
Doppler Echocardiography Doppler echocardiography procedures are add-on codes and must be listed separately in addition to the primary procedure. They are not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Intracardiac Echocardiography Intracardiac echocardiography is limited to one procedure per day for guidance of a catheter-based intervention. Intracardiac echocardiography is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Fetal Echocardiography Fetal Echocardiography is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the pregnant mother (fetus is the beneficiary) is transferred to a tertiary hospital for further specialized evaluation, the fetus has a change in clinical status, or guidance is needed during an interventional procedure.
Coronary Intravascular Ultrasound Coronary IVUS includes all transducer manipulations and repositioning within the specific vessel being examined, both before and after therapeutic intervention.
IVUS is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
One IVUS, initial vessel, is allowed per day. Three additional vessels are allowed per day, with the initial vessel IVUS.
Diagnosis Requirements
Specific covered indications for cardiovascular stress testing are: screening for coronary atherosclerosis and myocardial ischemia; follow-up after myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft to assess functional improvement during cardiac rehabilitation; follow-up of beneficiaries with palliated or unpalliated congenital heart disease; follow-up of pediatric and adult beneficiaries with dilated cardiomyopathy regardless of etiology; follow-up of pediatric and adult beneficiaries with hypertrophic cardiomyopathy; pre-operative assessment of beneficiaries being considered for valve replacement; and follow-up after valve replacement.
Place of Service
Inpatient, Outpatient, Office, Home, Intermediate care facility, Skilled nursing facility, and Independent Diagnostic Testing Facility
How to Submit
Please submit your request to Evolent
Resources
1E-7 Family Planning Services
Family Planning Medicaid services are provided to an eligible Medicaid beneficiary of childbearing age to temporarily or permanently prevent or delay pregnancy. Medicaid Family Planning is designed to reduce unintended pregnancies and improve the well-being of children and families in North Carolina.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
Limits
- • For FP Medicaid beneficiaries, these services are limited to services described in the policy's covered family planning service set.
- • Outpatient hospital registration is limited for FP Medicaid; the only allowed outpatient registered surgical procedure or service is sterilization, IUD removal, or ultrasound for IUD-related complications including missing strings.
- • Ultrasound for IUD placement issues may be performed only during an annual assessment, comprehensive preventive medicine evaluation, or inter-periodic visit.
- • Telehealth claims, when allowed under the policy, must be filed with the provider's usual place of service and not place of service 02.
Exclusions
Ultrasound is not covered to verify IUD placement at the time of insertion. Ultrasounds are not intended for routine checking of placement after IUD insertion. FP Medicaid does not cover medical conditions unrelated to family planning or family planning-related services. For FP Medicaid, surgical procedures or hospital services requiring outpatient beneficiary registration are not covered other than medically necessary contraceptive device removal or sterilizations; the policy note also identifies ultrasound for an IUD complication or removal of an IUD as exceptions to hospital cost responsibility. Hospital emergency room or emergency department services, inpatient hospital services, and treatment for acute or chronic conditions discovered during screening are not covered under FP Medicaid.
Place of Service
Non-Telehealth Claims: a. Inpatient hospitals (not applicable for a FP Medicaid beneficiary) b. Outpatient hospital: For a FP Medicaid beneficiary, the only surgical procedure or service allowed requiring outpatient beneficiary registration is sterilization, IUD removal or ultrasound for IUD related complications including missing strings. c. Office: utilizing offices within places of service 11 (Office), 19 (Off Campus Outpatient) or 22 (On Campus Outpatient) d. Ambulatory Surgical Centers (applicable for a FP Medicaid beneficiary for a sterilization. Numeric POS code(s): 02-Telehealth Provided Other than in Patient's Home.
Additional Service Specifics
FP. GT applies only when the service is telehealth billable and delivered by interactive audio-video.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Resources
Dialysis Service
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.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
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.
Additional Service Specifics
Once every three months
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Resources
Electrocardiography, Echocardiography, and Intravascular Ultrasound
Electrocardiography is a procedure for recording electrical changes in the heart. The electrocardiogram (ECG or EKG) shows the series of waves that relate to the electrical impulses that occur during each beat of the heart. EKGs can evaluate and detect cardiac problems. Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart. Ultrasound waves rebound or echo off the heart to show the size, shape, and movement of the heart's valves and chambers. Each component is crucial to permit a full assessment of the heart and an accurate diagnosis of certain cardiovascular diseases.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Reauthorization Guidelines
See the Turning Point site for specific requirements
Limits
Electrocardiogram A maximum of four, 12-lead EKGs is allowed per day.
Microvolt T-Wave Alternans Microvolt T-wave alternans is limited to once per day, regardless of whether it is performed while the beneficiary is at rest, during stress, or in a combination thereof.
The equipment used must be FDA approved for this indication and able to detect as little as 1 microvolt of T-wave alternans.
Holter Monitor The Holter monitor test is limited to one per 24-hour period.
Cardiac (Ambulatory) Event Monitors
- a. Event monitoring is limited to once per 30 days, regardless of the number of
transmissions.
- b. In order to bill any of the services that include 24-hour attended monitoring,
the provider must be available during the entire 24-hour period.
- c. The provider of the service must be capable of receiving and recording
transmissions, including receipt of the EKG signal as well as voice transmission relaying any associated symptoms.
- d. The person receiving the transmission must be a technician, nurse, or
physician trained in interpreting EKGs and clinical responses to abnormal EKGs.
- e. The transmission is reviewed for significant symptoms or EKG
abnormalities.
- f. Technicians should have immediate 24-hour access to a physician to review
transmitted data and make clinical decisions regarding the beneficiary.
- g. The provider must be capable of immediately notifying the beneficiary with
emergency instructions from the supervising or the attending physician, when appropriate.
- h. The emergency instructions for the beneficiary, as well as when and how to
contact available facilities to assist the beneficiary in case of emergencies, should be included by the attending physician in the referral for the monitoring Transthoracic Echocardiography TTE is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the beneficiary is transferred to a tertiary hospital for further specialized evaluation, the beneficiary has a change in clinical status, or guidance is needed during an interventional procedure.
Transesophageal Echocardiography TEE is limited to one per day for screening purposes.
Two intraoperative TEEs are allowed per day when performed during cardiac surgery as long as performed as part of the operative procedure. The preoperative (or pre-bypass) and post-operative (or post-bypass) components must be documented. Only the first intraoperative TEE can include the code for probe placement.
Doppler Echocardiography Doppler echocardiography procedures are add-on codes and must be listed separately in addition to the primary procedure. They are not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Intracardiac Echocardiography Intracardiac echocardiography is limited to one procedure per day for guidance of a catheter-based intervention. Intracardiac echocardiography is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Fetal Echocardiography Fetal Echocardiography is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the pregnant mother (fetus is the beneficiary) is transferred to a tertiary hospital for further specialized evaluation, the fetus has a change in clinical status, or guidance is needed during an interventional procedure.
Coronary Intravascular Ultrasound Coronary IVUS includes all transducer manipulations and repositioning within the specific vessel being examined, both before and after therapeutic intervention.
IVUS is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
One IVUS, initial vessel, is allowed per day. Three additional vessels are allowed per day, with the initial vessel IVUS.
Diagnosis Requirements
Specific covered indications for cardiovascular stress testing are: screening for coronary atherosclerosis and myocardial ischemia; follow-up after myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft to assess functional improvement during cardiac rehabilitation; follow-up of beneficiaries with palliated or unpalliated congenital heart disease; follow-up of pediatric and adult beneficiaries with dilated cardiomyopathy regardless of etiology; follow-up of pediatric and adult beneficiaries with hypertrophic cardiomyopathy; pre-operative assessment of beneficiaries being considered for valve replacement; and follow-up after valve replacement.
Place of Service
Inpatient, Outpatient, Office, Home, Intermediate care facility, Skilled nursing facility, and Independent Diagnostic Testing Facility
How to Submit
Please submit your request to Turning Point
Resources
Electrocardiography, Echocardiography, and Intravascular Ultrasound
Electrocardiography is a procedure for recording electrical changes in the heart. The electrocardiogram (ECG or EKG) shows the series of waves that relate to the electrical impulses that occur during each beat of the heart. EKGs can evaluate and detect cardiac problems. Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart. Ultrasound waves rebound or echo off the heart to show the size, shape, and movement of the heart's valves and chambers. Each component is crucial to permit a full assessment of the heart and an accurate diagnosis of certain cardiovascular diseases.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Reauthorization Guidelines
See the Turning Point site for specific requirements
Limits
Electrocardiogram A maximum of four, 12-lead EKGs is allowed per day.
Microvolt T-Wave Alternans Microvolt T-wave alternans is limited to once per day, regardless of whether it is performed while the beneficiary is at rest, during stress, or in a combination thereof.
The equipment used must be FDA approved for this indication and able to detect as little as 1 microvolt of T-wave alternans.
Holter Monitor The Holter monitor test is limited to one per 24-hour period.
Cardiac (Ambulatory) Event Monitors
- a. Event monitoring is limited to once per 30 days, regardless of the number of
transmissions.
- b. In order to bill any of the services that include 24-hour attended monitoring,
the provider must be available during the entire 24-hour period.
- c. The provider of the service must be capable of receiving and recording
transmissions, including receipt of the EKG signal as well as voice transmission relaying any associated symptoms.
- d. The person receiving the transmission must be a technician, nurse, or
physician trained in interpreting EKGs and clinical responses to abnormal EKGs.
- e. The transmission is reviewed for significant symptoms or EKG
abnormalities.
- f. Technicians should have immediate 24-hour access to a physician to review
transmitted data and make clinical decisions regarding the beneficiary.
- g. The provider must be capable of immediately notifying the beneficiary with
emergency instructions from the supervising or the attending physician, when appropriate.
- h. The emergency instructions for the beneficiary, as well as when and how to
contact available facilities to assist the beneficiary in case of emergencies, should be included by the attending physician in the referral for the monitoring Transthoracic Echocardiography TTE is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the beneficiary is transferred to a tertiary hospital for further specialized evaluation, the beneficiary has a change in clinical status, or guidance is needed during an interventional procedure.
Transesophageal Echocardiography TEE is limited to one per day for screening purposes.
Two intraoperative TEEs are allowed per day when performed during cardiac surgery as long as performed as part of the operative procedure. The preoperative (or pre-bypass) and post-operative (or post-bypass) components must be documented. Only the first intraoperative TEE can include the code for probe placement.
Doppler Echocardiography Doppler echocardiography procedures are add-on codes and must be listed separately in addition to the primary procedure. They are not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Intracardiac Echocardiography Intracardiac echocardiography is limited to one procedure per day for guidance of a catheter-based intervention. Intracardiac echocardiography is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Fetal Echocardiography Fetal Echocardiography is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the pregnant mother (fetus is the beneficiary) is transferred to a tertiary hospital for further specialized evaluation, the fetus has a change in clinical status, or guidance is needed during an interventional procedure.
Coronary Intravascular Ultrasound Coronary IVUS includes all transducer manipulations and repositioning within the specific vessel being examined, both before and after therapeutic intervention.
IVUS is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
One IVUS, initial vessel, is allowed per day. Three additional vessels are allowed per day, with the initial vessel IVUS.
Diagnosis Requirements
Specific covered indications for cardiovascular stress testing are: screening for coronary atherosclerosis and myocardial ischemia; follow-up after myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft to assess functional improvement during cardiac rehabilitation; follow-up of beneficiaries with palliated or unpalliated congenital heart disease; follow-up of pediatric and adult beneficiaries with dilated cardiomyopathy regardless of etiology; follow-up of pediatric and adult beneficiaries with hypertrophic cardiomyopathy; pre-operative assessment of beneficiaries being considered for valve replacement; and follow-up after valve replacement.
Place of Service
Inpatient, Outpatient, Office, Home, Intermediate care facility, Skilled nursing facility, and Independent Diagnostic Testing Facility
How to Submit
Please submit your request to Turning Point
Resources
Electrocardiography, Echocardiography, and Intravascular Ultrasound
Electrocardiography is a procedure for recording electrical changes in the heart. The electrocardiogram (ECG or EKG) shows the series of waves that relate to the electrical impulses that occur during each beat of the heart. EKGs can evaluate and detect cardiac problems. Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart. Ultrasound waves rebound or echo off the heart to show the size, shape, and movement of the heart's valves and chambers. Each component is crucial to permit a full assessment of the heart and an accurate diagnosis of certain cardiovascular diseases.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Reauthorization Guidelines
See the Turning Point site for specific requirements
Limits
Electrocardiogram A maximum of four, 12-lead EKGs is allowed per day.
Microvolt T-Wave Alternans Microvolt T-wave alternans is limited to once per day, regardless of whether it is performed while the beneficiary is at rest, during stress, or in a combination thereof.
The equipment used must be FDA approved for this indication and able to detect as little as 1 microvolt of T-wave alternans.
Holter Monitor The Holter monitor test is limited to one per 24-hour period.
Cardiac (Ambulatory) Event Monitors
- a. Event monitoring is limited to once per 30 days, regardless of the number of
transmissions.
- b. In order to bill any of the services that include 24-hour attended monitoring,
the provider must be available during the entire 24-hour period.
- c. The provider of the service must be capable of receiving and recording
transmissions, including receipt of the EKG signal as well as voice transmission relaying any associated symptoms.
- d. The person receiving the transmission must be a technician, nurse, or
physician trained in interpreting EKGs and clinical responses to abnormal EKGs.
- e. The transmission is reviewed for significant symptoms or EKG
abnormalities.
- f. Technicians should have immediate 24-hour access to a physician to review
transmitted data and make clinical decisions regarding the beneficiary.
- g. The provider must be capable of immediately notifying the beneficiary with
emergency instructions from the supervising or the attending physician, when appropriate.
- h. The emergency instructions for the beneficiary, as well as when and how to
contact available facilities to assist the beneficiary in case of emergencies, should be included by the attending physician in the referral for the monitoring Transthoracic Echocardiography TTE is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the beneficiary is transferred to a tertiary hospital for further specialized evaluation, the beneficiary has a change in clinical status, or guidance is needed during an interventional procedure.
Transesophageal Echocardiography TEE is limited to one per day for screening purposes.
Two intraoperative TEEs are allowed per day when performed during cardiac surgery as long as performed as part of the operative procedure. The preoperative (or pre-bypass) and post-operative (or post-bypass) components must be documented. Only the first intraoperative TEE can include the code for probe placement.
Doppler Echocardiography Doppler echocardiography procedures are add-on codes and must be listed separately in addition to the primary procedure. They are not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Intracardiac Echocardiography Intracardiac echocardiography is limited to one procedure per day for guidance of a catheter-based intervention. Intracardiac echocardiography is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Fetal Echocardiography Fetal Echocardiography is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the pregnant mother (fetus is the beneficiary) is transferred to a tertiary hospital for further specialized evaluation, the fetus has a change in clinical status, or guidance is needed during an interventional procedure.
Coronary Intravascular Ultrasound Coronary IVUS includes all transducer manipulations and repositioning within the specific vessel being examined, both before and after therapeutic intervention.
IVUS is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
One IVUS, initial vessel, is allowed per day. Three additional vessels are allowed per day, with the initial vessel IVUS.
Diagnosis Requirements
Specific covered indications for cardiovascular stress testing are: screening for coronary atherosclerosis and myocardial ischemia; follow-up after myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft to assess functional improvement during cardiac rehabilitation; follow-up of beneficiaries with palliated or unpalliated congenital heart disease; follow-up of pediatric and adult beneficiaries with dilated cardiomyopathy regardless of etiology; follow-up of pediatric and adult beneficiaries with hypertrophic cardiomyopathy; pre-operative assessment of beneficiaries being considered for valve replacement; and follow-up after valve replacement.
Place of Service
Inpatient, Outpatient, Office, Home, Intermediate care facility, Skilled nursing facility, and Independent Diagnostic Testing Facility
How to Submit
Please submit your request to Turning Point
Resources
Electrocardiography, Echocardiography, and Intravascular Ultrasound
Electrocardiography is a procedure for recording electrical changes in the heart. The electrocardiogram (ECG or EKG) shows the series of waves that relate to the electrical impulses that occur during each beat of the heart. EKGs can evaluate and detect cardiac problems. Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart. Ultrasound waves rebound or echo off the heart to show the size, shape, and movement of the heart's valves and chambers. Each component is crucial to permit a full assessment of the heart and an accurate diagnosis of certain cardiovascular diseases.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Reauthorization Guidelines
See the Turning Point site for specific requirements
Limits
Electrocardiogram A maximum of four, 12-lead EKGs is allowed per day.
Microvolt T-Wave Alternans Microvolt T-wave alternans is limited to once per day, regardless of whether it is performed while the beneficiary is at rest, during stress, or in a combination thereof.
The equipment used must be FDA approved for this indication and able to detect as little as 1 microvolt of T-wave alternans.
Holter Monitor The Holter monitor test is limited to one per 24-hour period.
Cardiac (Ambulatory) Event Monitors
- a. Event monitoring is limited to once per 30 days, regardless of the number of
transmissions.
- b. In order to bill any of the services that include 24-hour attended monitoring,
the provider must be available during the entire 24-hour period.
- c. The provider of the service must be capable of receiving and recording
transmissions, including receipt of the EKG signal as well as voice transmission relaying any associated symptoms.
- d. The person receiving the transmission must be a technician, nurse, or
physician trained in interpreting EKGs and clinical responses to abnormal EKGs.
- e. The transmission is reviewed for significant symptoms or EKG
abnormalities.
- f. Technicians should have immediate 24-hour access to a physician to review
transmitted data and make clinical decisions regarding the beneficiary.
- g. The provider must be capable of immediately notifying the beneficiary with
emergency instructions from the supervising or the attending physician, when appropriate.
- h. The emergency instructions for the beneficiary, as well as when and how to
contact available facilities to assist the beneficiary in case of emergencies, should be included by the attending physician in the referral for the monitoring Transthoracic Echocardiography TTE is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the beneficiary is transferred to a tertiary hospital for further specialized evaluation, the beneficiary has a change in clinical status, or guidance is needed during an interventional procedure.
Transesophageal Echocardiography TEE is limited to one per day for screening purposes.
Two intraoperative TEEs are allowed per day when performed during cardiac surgery as long as performed as part of the operative procedure. The preoperative (or pre-bypass) and post-operative (or post-bypass) components must be documented. Only the first intraoperative TEE can include the code for probe placement.
Doppler Echocardiography Doppler echocardiography procedures are add-on codes and must be listed separately in addition to the primary procedure. They are not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Intracardiac Echocardiography Intracardiac echocardiography is limited to one procedure per day for guidance of a catheter-based intervention. Intracardiac echocardiography is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Fetal Echocardiography Fetal Echocardiography is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the pregnant mother (fetus is the beneficiary) is transferred to a tertiary hospital for further specialized evaluation, the fetus has a change in clinical status, or guidance is needed during an interventional procedure.
Coronary Intravascular Ultrasound Coronary IVUS includes all transducer manipulations and repositioning within the specific vessel being examined, both before and after therapeutic intervention.
IVUS is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
One IVUS, initial vessel, is allowed per day. Three additional vessels are allowed per day, with the initial vessel IVUS.
Diagnosis Requirements
Specific covered indications for cardiovascular stress testing are: screening for coronary atherosclerosis and myocardial ischemia; follow-up after myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft to assess functional improvement during cardiac rehabilitation; follow-up of beneficiaries with palliated or unpalliated congenital heart disease; follow-up of pediatric and adult beneficiaries with dilated cardiomyopathy regardless of etiology; follow-up of pediatric and adult beneficiaries with hypertrophic cardiomyopathy; pre-operative assessment of beneficiaries being considered for valve replacement; and follow-up after valve replacement.
Place of Service
Inpatient, Outpatient, Office, Home, Intermediate care facility, Skilled nursing facility, and Independent Diagnostic Testing Facility
How to Submit
Please submit your request to Turning Point
Resources
Electrocardiography, Echocardiography, and Intravascular Ultrasound
Electrocardiography is a procedure for recording electrical changes in the heart. The electrocardiogram (ECG or EKG) shows the series of waves that relate to the electrical impulses that occur during each beat of the heart. EKGs can evaluate and detect cardiac problems. Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart. Ultrasound waves rebound or echo off the heart to show the size, shape, and movement of the heart's valves and chambers. Each component is crucial to permit a full assessment of the heart and an accurate diagnosis of certain cardiovascular diseases.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Reauthorization Guidelines
See the Turning Point site for specific requirements
Limits
Electrocardiogram A maximum of four, 12-lead EKGs is allowed per day.
Microvolt T-Wave Alternans Microvolt T-wave alternans is limited to once per day, regardless of whether it is performed while the beneficiary is at rest, during stress, or in a combination thereof.
The equipment used must be FDA approved for this indication and able to detect as little as 1 microvolt of T-wave alternans.
Holter Monitor The Holter monitor test is limited to one per 24-hour period.
Cardiac (Ambulatory) Event Monitors
- a. Event monitoring is limited to once per 30 days, regardless of the number of
transmissions.
- b. In order to bill any of the services that include 24-hour attended monitoring,
the provider must be available during the entire 24-hour period.
- c. The provider of the service must be capable of receiving and recording
transmissions, including receipt of the EKG signal as well as voice transmission relaying any associated symptoms.
- d. The person receiving the transmission must be a technician, nurse, or
physician trained in interpreting EKGs and clinical responses to abnormal EKGs.
- e. The transmission is reviewed for significant symptoms or EKG
abnormalities.
- f. Technicians should have immediate 24-hour access to a physician to review
transmitted data and make clinical decisions regarding the beneficiary.
- g. The provider must be capable of immediately notifying the beneficiary with
emergency instructions from the supervising or the attending physician, when appropriate.
- h. The emergency instructions for the beneficiary, as well as when and how to
contact available facilities to assist the beneficiary in case of emergencies, should be included by the attending physician in the referral for the monitoring Transthoracic Echocardiography TTE is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the beneficiary is transferred to a tertiary hospital for further specialized evaluation, the beneficiary has a change in clinical status, or guidance is needed during an interventional procedure.
Transesophageal Echocardiography TEE is limited to one per day for screening purposes.
Two intraoperative TEEs are allowed per day when performed during cardiac surgery as long as performed as part of the operative procedure. The preoperative (or pre-bypass) and post-operative (or post-bypass) components must be documented. Only the first intraoperative TEE can include the code for probe placement.
Doppler Echocardiography Doppler echocardiography procedures are add-on codes and must be listed separately in addition to the primary procedure. They are not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Intracardiac Echocardiography Intracardiac echocardiography is limited to one procedure per day for guidance of a catheter-based intervention. Intracardiac echocardiography is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Fetal Echocardiography Fetal Echocardiography is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the pregnant mother (fetus is the beneficiary) is transferred to a tertiary hospital for further specialized evaluation, the fetus has a change in clinical status, or guidance is needed during an interventional procedure.
Coronary Intravascular Ultrasound Coronary IVUS includes all transducer manipulations and repositioning within the specific vessel being examined, both before and after therapeutic intervention.
IVUS is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
One IVUS, initial vessel, is allowed per day. Three additional vessels are allowed per day, with the initial vessel IVUS.
Diagnosis Requirements
Specific covered indications for cardiovascular stress testing are: screening for coronary atherosclerosis and myocardial ischemia; follow-up after myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft to assess functional improvement during cardiac rehabilitation; follow-up of beneficiaries with palliated or unpalliated congenital heart disease; follow-up of pediatric and adult beneficiaries with dilated cardiomyopathy regardless of etiology; follow-up of pediatric and adult beneficiaries with hypertrophic cardiomyopathy; pre-operative assessment of beneficiaries being considered for valve replacement; and follow-up after valve replacement.
Place of Service
Inpatient, Outpatient, Office, Home, Intermediate care facility, Skilled nursing facility, and Independent Diagnostic Testing Facility
How to Submit
Please submit your request to Turning Point
Resources
Electrocardiography, Echocardiography, and Intravascular Ultrasound
Electrocardiography is a procedure for recording electrical changes in the heart. The electrocardiogram (ECG or EKG) shows the series of waves that relate to the electrical impulses that occur during each beat of the heart. EKGs can evaluate and detect cardiac problems. Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart. Ultrasound waves rebound or echo off the heart to show the size, shape, and movement of the heart's valves and chambers. Each component is crucial to permit a full assessment of the heart and an accurate diagnosis of certain cardiovascular diseases.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Limits
Electrocardiogram A maximum of four, 12-lead EKGs is allowed per day.
Microvolt T-Wave Alternans Microvolt T-wave alternans is limited to once per day, regardless of whether it is performed while the beneficiary is at rest, during stress, or in a combination thereof.
The equipment used must be FDA approved for this indication and able to detect as little as 1 microvolt of T-wave alternans.
Holter Monitor The Holter monitor test is limited to one per 24-hour period.
Cardiac (Ambulatory) Event Monitors
- a. Event monitoring is limited to once per 30 days, regardless of the number of
transmissions.
- b. In order to bill any of the services that include 24-hour attended monitoring,
the provider must be available during the entire 24-hour period.
- c. The provider of the service must be capable of receiving and recording
transmissions, including receipt of the EKG signal as well as voice transmission relaying any associated symptoms.
- d. The person receiving the transmission must be a technician, nurse, or
physician trained in interpreting EKGs and clinical responses to abnormal EKGs.
- e. The transmission is reviewed for significant symptoms or EKG
abnormalities.
- f. Technicians should have immediate 24-hour access to a physician to review
transmitted data and make clinical decisions regarding the beneficiary.
- g. The provider must be capable of immediately notifying the beneficiary with
emergency instructions from the supervising or the attending physician, when appropriate.
- h. The emergency instructions for the beneficiary, as well as when and how to
contact available facilities to assist the beneficiary in case of emergencies, should be included by the attending physician in the referral for the monitoring Transthoracic Echocardiography TTE is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the beneficiary is transferred to a tertiary hospital for further specialized evaluation, the beneficiary has a change in clinical status, or guidance is needed during an interventional procedure.
Transesophageal Echocardiography TEE is limited to one per day for screening purposes.
Two intraoperative TEEs are allowed per day when performed during cardiac surgery as long as performed as part of the operative procedure. The preoperative (or pre-bypass) and post-operative (or post-bypass) components must be documented. Only the first intraoperative TEE can include the code for probe placement.
Doppler Echocardiography Doppler echocardiography procedures are add-on codes and must be listed separately in addition to the primary procedure. They are not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Intracardiac Echocardiography Intracardiac echocardiography is limited to one procedure per day for guidance of a catheter-based intervention. Intracardiac echocardiography is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Fetal Echocardiography Fetal Echocardiography is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the pregnant mother (fetus is the beneficiary) is transferred to a tertiary hospital for further specialized evaluation, the fetus has a change in clinical status, or guidance is needed during an interventional procedure.
Coronary Intravascular Ultrasound Coronary IVUS includes all transducer manipulations and repositioning within the specific vessel being examined, both before and after therapeutic intervention.
IVUS is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
One IVUS, initial vessel, is allowed per day. Three additional vessels are allowed per day, with the initial vessel IVUS.
Diagnosis Requirements
Specific covered indications for cardiovascular stress testing are: screening for coronary atherosclerosis and myocardial ischemia; follow-up after myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft to assess functional improvement during cardiac rehabilitation; follow-up of beneficiaries with palliated or unpalliated congenital heart disease; follow-up of pediatric and adult beneficiaries with dilated cardiomyopathy regardless of etiology; follow-up of pediatric and adult beneficiaries with hypertrophic cardiomyopathy; pre-operative assessment of beneficiaries being considered for valve replacement; and follow-up after valve replacement.
Place of Service
Inpatient, Outpatient, Office, Home, Intermediate care facility, Skilled nursing facility, and Independent Diagnostic Testing Facility
How to Submit
Please submit your request to Evolent
Resources
Dialysis Service
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.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
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.
Additional Service Specifics
Once every three months
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Resources
Electrocardiography, Echocardiography, and Intravascular Ultrasound
Electrocardiography is a procedure for recording electrical changes in the heart. The electrocardiogram (ECG or EKG) shows the series of waves that relate to the electrical impulses that occur during each beat of the heart. EKGs can evaluate and detect cardiac problems. Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart. Ultrasound waves rebound or echo off the heart to show the size, shape, and movement of the heart's valves and chambers. Each component is crucial to permit a full assessment of the heart and an accurate diagnosis of certain cardiovascular diseases.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Limits
Electrocardiogram A maximum of four, 12-lead EKGs is allowed per day.
Microvolt T-Wave Alternans Microvolt T-wave alternans is limited to once per day, regardless of whether it is performed while the beneficiary is at rest, during stress, or in a combination thereof.
The equipment used must be FDA approved for this indication and able to detect as little as 1 microvolt of T-wave alternans.
Holter Monitor The Holter monitor test is limited to one per 24-hour period.
Cardiac (Ambulatory) Event Monitors
- a. Event monitoring is limited to once per 30 days, regardless of the number of
transmissions.
- b. In order to bill any of the services that include 24-hour attended monitoring,
the provider must be available during the entire 24-hour period.
- c. The provider of the service must be capable of receiving and recording
transmissions, including receipt of the EKG signal as well as voice transmission relaying any associated symptoms.
- d. The person receiving the transmission must be a technician, nurse, or
physician trained in interpreting EKGs and clinical responses to abnormal EKGs.
- e. The transmission is reviewed for significant symptoms or EKG
abnormalities.
- f. Technicians should have immediate 24-hour access to a physician to review
transmitted data and make clinical decisions regarding the beneficiary.
- g. The provider must be capable of immediately notifying the beneficiary with
emergency instructions from the supervising or the attending physician, when appropriate.
- h. The emergency instructions for the beneficiary, as well as when and how to
contact available facilities to assist the beneficiary in case of emergencies, should be included by the attending physician in the referral for the monitoring Transthoracic Echocardiography TTE is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the beneficiary is transferred to a tertiary hospital for further specialized evaluation, the beneficiary has a change in clinical status, or guidance is needed during an interventional procedure.
Transesophageal Echocardiography TEE is limited to one per day for screening purposes.
Two intraoperative TEEs are allowed per day when performed during cardiac surgery as long as performed as part of the operative procedure. The preoperative (or pre-bypass) and post-operative (or post-bypass) components must be documented. Only the first intraoperative TEE can include the code for probe placement.
Doppler Echocardiography Doppler echocardiography procedures are add-on codes and must be listed separately in addition to the primary procedure. They are not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Intracardiac Echocardiography Intracardiac echocardiography is limited to one procedure per day for guidance of a catheter-based intervention. Intracardiac echocardiography is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Fetal Echocardiography Fetal Echocardiography is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the pregnant mother (fetus is the beneficiary) is transferred to a tertiary hospital for further specialized evaluation, the fetus has a change in clinical status, or guidance is needed during an interventional procedure.
Coronary Intravascular Ultrasound Coronary IVUS includes all transducer manipulations and repositioning within the specific vessel being examined, both before and after therapeutic intervention.
IVUS is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
One IVUS, initial vessel, is allowed per day. Three additional vessels are allowed per day, with the initial vessel IVUS.
Diagnosis Requirements
Specific covered indications for cardiovascular stress testing are: screening for coronary atherosclerosis and myocardial ischemia; follow-up after myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft to assess functional improvement during cardiac rehabilitation; follow-up of beneficiaries with palliated or unpalliated congenital heart disease; follow-up of pediatric and adult beneficiaries with dilated cardiomyopathy regardless of etiology; follow-up of pediatric and adult beneficiaries with hypertrophic cardiomyopathy; pre-operative assessment of beneficiaries being considered for valve replacement; and follow-up after valve replacement.
Place of Service
Inpatient, Outpatient, Office, Home, Intermediate care facility, Skilled nursing facility, and Independent Diagnostic Testing Facility
How to Submit
Please submit your request to Evolent
Resources
Dialysis Service
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.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
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.
Additional Service Specifics
Once every three months
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Resources
Electrocardiography, Echocardiography, and Intravascular Ultrasound
Electrocardiography is a procedure for recording electrical changes in the heart. The electrocardiogram (ECG or EKG) shows the series of waves that relate to the electrical impulses that occur during each beat of the heart. EKGs can evaluate and detect cardiac problems. Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart. Ultrasound waves rebound or echo off the heart to show the size, shape, and movement of the heart's valves and chambers. Each component is crucial to permit a full assessment of the heart and an accurate diagnosis of certain cardiovascular diseases.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Limits
Electrocardiogram A maximum of four, 12-lead EKGs is allowed per day.
Microvolt T-Wave Alternans Microvolt T-wave alternans is limited to once per day, regardless of whether it is performed while the beneficiary is at rest, during stress, or in a combination thereof.
The equipment used must be FDA approved for this indication and able to detect as little as 1 microvolt of T-wave alternans.
Holter Monitor The Holter monitor test is limited to one per 24-hour period.
Cardiac (Ambulatory) Event Monitors
- a. Event monitoring is limited to once per 30 days, regardless of the number of
transmissions.
- b. In order to bill any of the services that include 24-hour attended monitoring,
the provider must be available during the entire 24-hour period.
- c. The provider of the service must be capable of receiving and recording
transmissions, including receipt of the EKG signal as well as voice transmission relaying any associated symptoms.
- d. The person receiving the transmission must be a technician, nurse, or
physician trained in interpreting EKGs and clinical responses to abnormal EKGs.
- e. The transmission is reviewed for significant symptoms or EKG
abnormalities.
- f. Technicians should have immediate 24-hour access to a physician to review
transmitted data and make clinical decisions regarding the beneficiary.
- g. The provider must be capable of immediately notifying the beneficiary with
emergency instructions from the supervising or the attending physician, when appropriate.
- h. The emergency instructions for the beneficiary, as well as when and how to
contact available facilities to assist the beneficiary in case of emergencies, should be included by the attending physician in the referral for the monitoring Transthoracic Echocardiography TTE is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the beneficiary is transferred to a tertiary hospital for further specialized evaluation, the beneficiary has a change in clinical status, or guidance is needed during an interventional procedure.
Transesophageal Echocardiography TEE is limited to one per day for screening purposes.
Two intraoperative TEEs are allowed per day when performed during cardiac surgery as long as performed as part of the operative procedure. The preoperative (or pre-bypass) and post-operative (or post-bypass) components must be documented. Only the first intraoperative TEE can include the code for probe placement.
Doppler Echocardiography Doppler echocardiography procedures are add-on codes and must be listed separately in addition to the primary procedure. They are not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Intracardiac Echocardiography Intracardiac echocardiography is limited to one procedure per day for guidance of a catheter-based intervention. Intracardiac echocardiography is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
Fetal Echocardiography Fetal Echocardiography is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the pregnant mother (fetus is the beneficiary) is transferred to a tertiary hospital for further specialized evaluation, the fetus has a change in clinical status, or guidance is needed during an interventional procedure.
Coronary Intravascular Ultrasound Coronary IVUS includes all transducer manipulations and repositioning within the specific vessel being examined, both before and after therapeutic intervention.
IVUS is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.
One IVUS, initial vessel, is allowed per day. Three additional vessels are allowed per day, with the initial vessel IVUS.
Diagnosis Requirements
Specific covered indications for cardiovascular stress testing are: screening for coronary atherosclerosis and myocardial ischemia; follow-up after myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft to assess functional improvement during cardiac rehabilitation; follow-up of beneficiaries with palliated or unpalliated congenital heart disease; follow-up of pediatric and adult beneficiaries with dilated cardiomyopathy regardless of etiology; follow-up of pediatric and adult beneficiaries with hypertrophic cardiomyopathy; pre-operative assessment of beneficiaries being considered for valve replacement; and follow-up after valve replacement.
Place of Service
Inpatient, Outpatient, Office, Home, Intermediate care facility, Skilled nursing facility, and Independent Diagnostic Testing Facility
How to Submit
Please submit your request to Evolent
Resources
Dialysis Service
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.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
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.
Additional Service Specifics
Once every three months
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Resources
Interrogation device evaluation (in person), carotid sinus baroreflex activation therapy (BAT) modulation system including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with int
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Interrogation device evaluation (in person), carotid sinus baroreflex activation therapy (BAT) modulation system including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with int
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
If you find any wrong or out of date information on our pages, we want to know. Please email info@TrilliumNC.org with any corrections.