Description:

This policy addresses reimbursement for dialysis services.

Definitions:

End Stage Renal Disease (ESRD) can be treated by either hemodialysis or peritoneal dialysis. Both dialysis treatments remove waste and extra fluid from the body. Hemodialysis is treated with the help of an apparatus called a dialyzer while peritoneal dialysis uses a combination of the lining of the peritoneal membrane and a solution.

Policy:

Home hemodialysis is commonly done in more frequent, shorter episodes than outpatient hemodialysis with similar outcomes. Reimbursement limits the number of composite rates for hemodialysis to three per calendar week (Sunday through Saturday). BCBSND will reimburse the same weekly rate for home hemodialysis as it does for traditional outpatient hemodialysis. Only the first three composite rates billed in one week with revenue code 0821 will be allowed, additional composite rates will be denied as provider liable.

Self-Dialysis Training is reimbursed for dialysis units and/or centers that train dialysis patients to self-dialyze at home or in self-dialysis units at facilities. This applies to all dialysis modalities (hemodialysis, Continuous Ambulatory Peritoneal Dialysis (CAPD) or Continuous Cycling Peritoneal Dialysis (CCPD)) where training is furnished. Reimbursement will be based on the completed course. If the training course is not completed, each session should be billed separately. Reimbursement will be based on the number of sessions completed, not to exceed 25.

Reimbursement for dialysis services includes any support services provided. Charges billed separately with a dialysis support services revenue code will be denied as included in the dialysis rate.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

• Group or Individual benefit
• Provider Participation Agreement
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
• Mandated or legislative required criteria will always supersede.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

Cross Reference:

Home Dialysis Equipment and Supplies Medical Policy

History: