Chapter 15                                                                                Dialysis Supplies

Local Medical...
Dialysis Supplies                                                                           Chapter 15
A4737 Injectable an...
Chapter 15                                                                               Dialysis Supplies
E1600 Delivery ...
Dialysis Supplies                                                                                  Chapter 15
          1)...
Chapter 15                                                                                Dialysis Supplies
conventional h...
Dialysis Supplies                                                                                  Chapter 15
available to...
Chapter 15                                                           Dialysis Supplies




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Local Medical Review Policies (LMRPs)

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Local Medical Review Policies (LMRPs)

  1. 1. Chapter 15 Dialysis Supplies Local Medical Review Policies (LMRPs) 15.01 Home Dialysis Supplies and Equipment HCPCS Codes The appearance of a code in this section does not necessarily indicate coverage. A4651 Calibrated microcapillary tube, each A4652 Microcapillary tube sealant A4656 Needle, any size, for dialysis, each A4657 Syringe, with or without needle, for dialysis, each A4660 Sphygmomanometer/blood pressure apparatus with cuff and stethoscope, for dialysis A4663 Blood pressure cuff only, for dialysis A4670 Automatic blood pressure monitor, for dialysis A4680 Activated carbon filter for hemodialysis, each A4690 Dialyzer (artificial kidneys), all types, all sizes, for hemodialysis, each A4706 Bicarbonate concentrate, solution, for hemodialysis, per gallon A4707 Bicarbonate concentrate, powder, for hemodialysis, per packet A4708 Acetate concentrate solution, for hemodialysis, per gallon A4709 Acid concentrate, solution, for hemodialysis, per gallon A4712 Water, sterile, for injection for dialysis, per 10 ml A4714 Treated water (deionized, distilled, or reverse osmosis) for peritoneal dialysis, per gallon A4719 "Y set" tubing for peritoneal dialysis A4720 Dialysate solution, any concentration of dextrose, fluid volume of greater than 249 cc, but less than or equal to 999 cc, for peritoneal dialysis A4721 Dialysate solution, any concentration of dextrose, fluid volume greater than 999 cc but less than or equal to 1999 cc, for peritoneal dialysis A4722 Dialysate solution, any concentration of dextrose, fluid volume greater than 1999 cc but less than or equal to 2999 cc, for peritoneal dialysis A4723 Dialysate solution, any concentration of dextrose, fluid volume greater than 2999 cc but less than or equal to 3999 cc, for peritoneal dialysis A4724 Dialysate solution, any concentration of dextrose, fluid volume greater than 3999 cc but less than or equal to 4999 cc, for peritoneal dialysis A4725 Dialysate solution, any concentration of dextrose, fluid volume greater than 4999 cc but less than or equal to 5999 cc, for peritoneal dialysis A4726 Dialysate solution, any concentration of dextrose, fluid volume greater than 5999 cc, for peritoneal dialysis A4730 Fistula cannulation set for hemodialysis, each A4736 Topical anesthetic, for dialysis, per gram Region A DMERC Supplier Manual (Rev. 21, 03/02) 15.01-1
  2. 2. Dialysis Supplies Chapter 15 A4737 Injectable anesthetic, for dialysis, per 10 ml A4740 Shunt accessory, for hemodialysis, any type, each A4750 Blood tubing, arterial or venous, for hemodialysis, each A4755 Blood tubing, arterial and venous combined, for hemodialysis, each A4760 Dialysate solution test kit, for peritoneal dialysis, any type, each A4765 Dialysate concentrate, powder, additives, for peritoneal dialysis, per packet A4766 Dialysate concentrate, solution, additive for peritoneal dialysis, per 10 ml A4770 Blood collection tube, vacuum, for dialysis, per 50 A4771 Serum clotting time tube, for dialysis, per 50 A4772 Blood glucose test strips, for dialysis, per 50 A4773 Occult blood test strips, for dialysis, per 50 A4774 Ammonia test strips, for dialysis, per 50 A4801 Heparin, any type for hemodialysis, per 1,000 units A4802 Protamine sulfate, for hemodialysis, per 50 mg A4860 Disposable catheter tips for peritoneal dialysis, per 10 A4870 Plumbing and/or electrical work for home hemodialysis equipment A4890 Contracts, repair and maintenance, for hemodialysis equipment A4911 Drain bag/bottle, for dialysis, each A4913 Miscellaneous dialysis supplies, not otherwise specified A4918 Venous pressure clamps, for hemodialysis, each A4927 Gloves, non-sterile, for dialysis, per 100 A4928 Surgical mask, for dialysis, per 20 A4929 Tourniquet, for dialysis, each E1500 Centrifuge, for dialysis E1510 Kidney, dialysate delivery system kidney machine, pump recirculating, air removal system, flowrate meter, power off, heater and temperature control with alarm, IV poles, pressure gauge, concentrate container E1520 Heparin infusion pump for hemodialysis E1530 Air bubble detector for hemodialysis, each, replacement E1540 Pressure alarm for hemodialysis, each, replacement E1550 Bath conductivity meter for hemodialysis, each E1560 Blood leak detector for hemodialysis, each, replacement E1570 Adjustable chair, for ESRD patients E1575 Transducer protectors/fluid barriers, for hemodialysis, any size, per 10 E1580 Unipuncture control system for hemodialysis E1590 Hemodialysis machine E1592 Automatic intermittent peritoneal dialysis system E1594 Cycler dialysis machine for peritoneal dialysis 15.01-2 Region A DMERC Supplier Manual (Rev. 21, 03/02)
  3. 3. Chapter 15 Dialysis Supplies E1600 Delivery and/or installation charges for hemodialysis equipment E1610 Reverse osmosis water purification system, for hemodialysis E1615 Deionizer water purification system, for hemodialysis E1620 Blood pump for hemodialysis, replacement E1625 Water softening system, for hemodialysis E1630 Reciprocating peritoneal dialysis system E1632 Wearable artificial kidney, each E1635 Compact (portable) travel hemodialyzer system E1636 Sorbent cartridges, for hemodialysis, per 10 E1637 Hemostats, for dialysis, each E1638 Heating pad, for peritoneal dialysis, any size, each E1639 Scale, for dialysis, each E1699 Dialysis equipment, not otherwise specified HCPCS Modifiers EM Emergency reserve supply KX Specific required documentation on file Benefit Category Dialysis supplies and equipment References Coverage Issues Manual 55-1, 55-2, 55-3 Coverage And Payment Rules For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, "reasonable and necessary" are defined by the following coverage and payment rules. Home dialysis supplies and equipment are covered when they are reasonable and necessary for patients with end stage renal disease (ESRD) who are being dialyzed at home under the supervision of a Medicare approved dialysis facility. When a beneficiary has chosen to receive home dialysis supplies and equipment from a dialysis facility (Method I), those claims are processed by the Medicare intermediary. The DMERC processes claims for beneficiaries who have chosen to receive their supplies and equipment from an independent supplier (Method II). This policy only concerns supplies and equipment furnished under Method II. Suppliers' claims will be covered only if all of the following conditions are met: Region A DMERC Supplier Manual (Rev. 21, 03/02) 15.01-3
  4. 4. Dialysis Supplies Chapter 15 1) The beneficiary has elected to receive home dialysis equipment and supplies from an independent supplier. 2) The supplier is not a Medicare approved dialysis facility. 3) The supplier agrees to receive Medicare payment only on an assignment-related basis. 4) The supplier agrees to be the beneficiary's sole supplier for all home dialysis equipment and supplies. 5) Supplier agrees to bill on a monthly basis for the quantity of supplies appropriate for that period. (However, there is one exception to this rule. Beneficiaries are permitted to have one month's supplies in reserve in case of emergency.) 6) The supplier has a written agreement with a Medicare approved dialysis facility under which the facility will furnish all necessary support, backup, and emergency dialysis services. (For Medicare beneficiaries who are also entitled to military or veterans' benefits, a military or Veterans' Administration hospital satisfies this requirement.) The dialysis facility must be a reasonable distance from the beneficiary's home in order to furnish these services. A reasonable distance is determined by taking into account variables such as terrain, whether the patient's home is located in an urban or rural area, and the usual distances traveled and time in transit by patients in the area in obtaining health care services. 7) The supplier reports to the back-up facility within 30 days all items and services that it furnishes to the patient so that the facility can record this information in the patient's medical record. The supplies and equipment are reasonable and necessary for that patient. Continuous cycling peritoneal dialysis (CCPD) is covered if the patient has one or more of the following indications: 1) Frequent episodes of peritonitis; or 2) A patient who is incapable of performing peritoneal dialysis without assistance; or 3) A patient who, in the physician's determination, cannot be adequately dialyzed with continuous ambulatory peritoneal dialysis (CAPD). The medical necessity for CCPD must be clearly documented in the patient's medical record and may be requested by the DMERC. If CCPD is not medically necessary, but the patient is covered for home dialysis, payment will be made for the least costly alternative, the lesser of the reasonable charge allowance for the equipment and supplies or the Medicare monthly payment limit. Water purification systems are covered for patients on home hemodialysis. Medicare will cover either a deionization (E1615) or reverse osmosis (E1610) system, but not both for the same patient at the same time. A water softening system (E1625) is covered for patients on home hemodialysis only if all of the following conditions are met: 1) The patient has a reverse osmosis (RO) purification system and the manufacturer of the RO unit has set standards for the quality of water entering the RO (e.g., the water to be purified by the RO must be of a certain quality if the unit is to perform as intended); and 2) The patient's water is demonstrated to be of a lesser quality than required; and 3) The softener is used only to soften water entering the RO unit, and thus, used only for dialysis. (The softener need not actually be built into the RO unit, but must be an integral part of the dialysis system.) Spare deionization tanks are not medically necessary since they are essentially a precautionary supply. Activated carbon filters (A4680) used as a component of water purification systems to remove unsafe concentration of chloride or chloramines are covered when prescribed by a physician. An ultrafiltration monitor (E1699) is not medically necessary when the ultrafiltration is independant of 15.01-4 Region A DMERC Supplier Manual (Rev. 21, 03/02)
  5. 5. Chapter 15 Dialysis Supplies conventional hemodialysis. A Peridex filter set (A4913) used with peritoneal dialysis will be denied as not medically necessary. The following parenteral medications/solutions are included in the Medicare monthly payment limit and are not separately payable: heparin, heparin antidote (protamine), mannitol, glucose (dextrose), saline, local anesthetics, antiarrhythmics, antihypertensives, pressor drugs, antibiotics (when used to treat an infection of the catheter site or peritonitis associated with peritoneal dialysis). Back-up equipment supplied in anticipation of the need for substitution or replacement will be denied as not medically necessary. Rental of equipment while patient owned equipment is being repaired is covered. Repairs and maintenance for rented equipment are included in the rental allowance. Repairs for beneficiary owned equipment are covered and separately reimbursed. Repair and maintenance (A4890) contracts (i.e., fees paid in anticipation of the need for service) will be denied as included in the allowances for the equipment. Medicare covers only costs incurred for services furnished. Emergency reserve supplies are allowed for patients on dialysis to anticipate short-term increased use of supplies or delays in supply delivery. Up to a one month's supplies is covered, but this is a one-time lifetime allowance. If supplies from the reserve are used, replacement of them must be billed along with the other supplies used during the month, without the EM modifier. The allowance per month under Method II for home dialysis supplies and equipment (A46510-A4929, E1500-E1699) is the lesser of (a) the reasonable charge of allowance for all medically necessary equipment and supplies used, or (b) the Medicare monthly payment limit for all forms of dialysis except CCPD. For CCPD, the allowance is the lesser of the reasonable charge allowance or the Medicare monthly payment limit. Coding Guidelines Codes A4651-A4929, E1500-E1699, may be used only for supplies and equipment relating to home dialysis. Items not related to dialysis should not be listed in the miscellaneous codes (A4913 or E1699). Conversely, supplies and equipment relating to home dialysis should not be billed using other HCPCS codes. Dialysis supply kits are no longer valid for submission to the DMERCs; bill HCPCS codes describing individual items supplied. Miscellaneous medications, such as antibiotics covered under this benefit (see Coverage and Payment Rules), should be coded A4913. J series HCPCS codes must not be used. Code E1594 should be billed for each month that the patient receives CCPD. An EM modifier must be added each month to a dialysis supply code when appropriate. Suppliers should contact the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) for guidance on the correct coding of these devices. Documentation Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider" (42 U.S.C. § 1395l(e)). It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be Region A DMERC Supplier Manual (Rev. 21, 03/02) 15.01-5
  6. 6. Dialysis Supplies Chapter 15 available to the DMERC upon request. If the beneficiary meets all the criteria specified in the Coverage and Payment Rules section for this policy, including a written agreement between the supplier and a Medicare certified support service facility within a reasonable distance from the beneficiary’s home, the KX modifier must be added to each dialysis code. The KX modifier may only be used when these requirements are met. An order for the supplies or equipment, which is signed and dated by the ordering physician, must be kept on file by the supplier. The patient's medical records must contain information which supports the medical necessity of the items ordered. The appropriate ICD-9 diagnosis code for dialysis (V45.1) should be referenced on each claim. If a miscellaneous supply or equipment code (A4913 or E1699) is used, the claim must include a narrative which adequately describes each item billed using the miscellaneous codes. If billing for repair of patient owned dialysis equipment, use code E1699, which must be accompanied by a narrative description of what is being repaired. The supplier must have on file a copy of the ESRD Beneficiary Selection form (HCFA Form 382). The supplier must have on file the original written agreement with a Medicare approved dialysis facility (or military or VA hospital) which specifies that it will provide at least the following services: 1) Surveillance of the patient's home adaptation, including provisions for visits to the home or the facility; 2) Consultation for the patient with a qualified social worker and a qualified dietician; 3) Maintain a record keeping system which assures continuity of care and includes a record of supplies and equipment provided by the Method II supplier; 4) Maintaining and submitting all required documentation to the ESRD network; 5) Assuring that the water supply is of the appropriate quality if hemodialysis is the dialysis method; 6) Assuring that the appropriate supplies are ordered on an ongoing basis; 7) Arranging for the provision of all ESRD related laboratory tests, and billing for the laboratory tests that are included in the composition rate; 8) Furnishing institutional dialysis services and supplies; 9) Furnishing dialysis-related emergency services, and 10) Furnishing all other necessary dialysis services and supplies. Refer to the Supplier Manual for more information on orders, medical records and documentation. Effective Date Claims with dates of service on or after July 1, 2002. This is a revision to a previously published policy. 15.01-6 Region A DMERC Supplier Manual (Rev. 21, 03/02)
  7. 7. Chapter 15 Dialysis Supplies This page intentionally left blank. Region A DMERC Supplier Manual (Rev. 21, 03/02) 15.01-7

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