Note: Under EAPG Grouper Version 3.14, if CPT code 90999 is billed, the service will process as peritoneal dialysis. For EAPG Grouper Version 3.16 and later, all dialysis codes will group to a single EAPG and therefore 90999 can be billed for either hemodialysis or peritoneal dialysis.
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, payment integrity edits 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:
Date
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Updates
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04/01/2020
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Created Dialysis Services reimbursement policy.
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9/30/2021
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Removed statement “Reimbursement will be based on the number of sessions completed, not to exceed 25.” Please reference member benefits for how many sessions are covered. Added billing guidelines for claims processed under the EAPG system.
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4/28/2022
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Updated the note under EAPGs to show that all dialysis will code to a single EAPG with the update to grouper version 3.16.
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6/30/2022
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Corrected policy number from NDRP-GC-025 to NDRP-GC-026.
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4/21/2023
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Annual review of policy completed. Added note regarding HCPCS code A4657 will not be paid separately if charged on the same day the dialysis service is rendered.
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9/15/2024
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Removed the billing table for non-EAPG claims.
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3/14/2025
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Added requirement for Medicaid Expansion claims to bill both value codes 48 & 49.
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