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Date Printed: October 25, 2014: 01:25 PM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2014, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-90918-01

Original Effective Date: 01/01/02

Reviewed: 10/22/09

Revised: 05/11/14

Subject: Home Dialysis Services, Supplies, Equipment, and Accessories

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions
Other References Updates  

DESCRIPTION:

Chronic renal failure (CRF) is a progressive disease characterized by an increasing inability of the kidney to maintain normal low levels of the products of protein metabolism (i.e., urea), normal blood pressure and hematocrit, and sodium, water, potassium, and acid-base balance. Renal function is clinically monitored by measurement of serum creatinine and blood urea nitrogen (BUN) and by urinalysis. Once serum creatinine in an adult reaches about 3 mg/dL and no factors in the pathogenesis of the renal disease are reversible, typically the renal disease progresses to end-stage renal disease (ESRD) over a very variable period (from a few years to as many as 20 to 25 years). Unless contraindications are present, such as terminal irreversible disease in another organ system or the patient does not wish it, almost all patients in industrialized nations then receive renal replacement therapy (RRT).

Hemodialysis uses blood pumps for ultrafiltration, whereas peritoneal dialysis uses the osmotic forces of high concentrations of glucose to remove water.

Patients on peritoneal dialysis are slightly younger than those on hemodialysis. They have fewer co-morbid conditions. On the other hand, patients whose renal failure is due to diabetes mellitus often are placed on peritoneal dialysis because insulin delivery can be simplified by infusing it with the dialysate. There are no controlled trials that compare survival rates between hemodialysis and peritoneal dialysis.

Patient selection for these two different forms of treatment is usually decided by special needs of the patient and the nephrologist's clinical judgment of which treatment will be best tolerated.

There is more long-term experience with hemodialysis and many patients who start peritoneal dialysis switch to hemodialysis before they finish a year of treatment.

This guideline does not address dialysis services provided in outpatient dialysis centers, but discusses only dialysis services, supplies, equipment, and accessories used in the home setting.

POSITION STATEMENT:

Dialysis services, supplies, equipment (durable medical equipment), and associated accessories meet the definition of medical necessity when provided for patients with end stage renal disease (ESRD).

Monthly and daily pro-rated end stage renal disease (ESRD) services reflect management of patients receiving hemodialysis, peritoneal dialysis, continuous ambulatory peritoneal dialysis (CAPD), and other forms of self-dialysis. These services may be performed at home or in an outpatient facility and may include the following:

Supplies used for home dialysis may include the following:

Supplies such as syringes, needles, heparin, and declotting equipment (declotting catheter/aspirator, Teflon insert) meet the definition of medical necessity when used to:

Medical supplies that can be purchased over-the-counter are generally considered contract exclusions and are non-covered.

The following associated medical supplies may be reimbursed separately, in addition to the primary dialysis service:

The following home peritoneal dialysis supplies meet the definition of medical necessity and may include the following:

Surgical dressings meet the definition of medical necessity when they are:

Exchange or replacement storage tanks used in connection with water purification systems; meet the definition of medical necessity provided the tank is necessary for use during dialysis treatment and not obtained as a precautionary (spare) supply.

Water (i.e., deionized water, distilled water, and water treated by reverse osmosis) meets the definition of medical necessity when:

Reimbursement is based on reasonable charge or itemized invoice.

Dialysis training courses, completed (90989) or not completed (90993), meet the definition of medical necessity and are limited to one (1) completed course or one (1) not completed course.

DME and associated accessories for home hemodialysis meet the definition of medical necessity and typically includes the following:

Kidney dialysate delivery system that usually includes:

DME for home peritoneal dialysis may include:

Reimbursement is limited to one of the automatic delivery systems or the utility bath.

DME that is not used for hemodialysis or peritoneal dialysis during the time period in which reimbursement is made for rental or purchase of the equipment meets the definition of medical necessity when one of the following conditions exists:

Reimbursement is made for the rental or purchase for a period not to exceed three (3) months after the month in which it was used.

Dialysis equipment (DME) used to supplement hemodialysis or peritoneal dialysis during CAPD training meets the definition of medical necessity. Reimbursement is limited to the rental or purchase of the dialysis equipment for a period up to 3 months after the completion of the CAPD training.

Water softening systems used in conjunction with home hemodialysis or peritoneal dialysis meets the definition of medical necessity when the system is:

Claims for this service require documentation of these coverage provisions. Reimbursement is based on invoice cost.

Compact (portable) travel hemodialysis systems meet the definition of medical necessity when:

Reimbursement is limited to rental charges, not to exceed three (3) months. Reimbursement for a stationary dialysis machine is made in addition to the allowance for a compact travel hemodialyzer system.

Water purification systems that replace a water softening system in a home dialysis system meets the definition of medical necessity, but is subject to medical review of documentation in support of medical necessity.

Delivery and/or installation charges for dialysis equipment meet the definition of medical necessity provided:

Reimbursement is made on a lump-sum basis and not on an installment plan.

Replacement components for hemodialysis OR peritoneal dialysis machines meet the definition of medical necessity provided the equipment is owned or is being purchased. Reimbursement is based on itemized invoice.

Replacement of home dialysis equipment may be covered when:

Reimbursement for replacements required because of loss or irreparable damage or wear, may be made without a physician's order if the equipment still meets the patient's medical needs.

Labor charges for home dialysis equipment repair OR to replace machine components meet the definition of medical necessity when the equipment is owned or is being purchased. Reimbursement is made on a per hour basis.

Travel time to repair home dialysis equipment or to replace machine components meets the definition of medical necessity when:

Reimbursement for travel is made on a per-mile basis.

Plumbing OR electrical work for home dialysis equipment meets the definition of medical necessity when the services rendered are necessary to tie in with water OR power lines which already exist. Reimbursement is based on invoice cost.

Hemodialysis for the treatment of schizophrenia is considered experimental or investigational, as there is insufficient clinical evidence to support the use of hemodialysis for the treatment of schizophrenia. Scientific evidence does not support the safety and effectiveness of this therapy.

LOINC Codes:

The following information may be required documentation to support medical necessity: e.g., attending physician history and physical, attending physician visit notes, other pertinent information such as nursing home records, home health agency records, and records from other healthcare professionals.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician operative report

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Pathology report

27898-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Clinical notes and chart section (i.e., nursing home records, home health agency records, and other health care professional

28650-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

BILLING/CODING INFORMATION:

The following CPT and HCPCS Level II codes may be used to describe dialysis services, equipment, and supplies/accessories.

CPT Coding:

90963

End-stage renal disease (ESRD) related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

90964

End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

90965

End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

90966

End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 20 years of age and older

90967

End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age

90968

End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 2-11 years of age

90969

End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for 12-19 years of age

90970

End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 20 years of age and older

90989

Dialysis training, patient, including helper where applicable, any mode, completed course

90993

Dialysis training, patient including helper where applicable, any mode, course not completed, per training

90997

Hemoperfusion (e.g., with activated charcoal or resin)

90999

Unlisted dialysis procedure, inpatient or outpatient

93990

Duplex scan of hemodialysis access (including arterial inflow, body of access, and venous outflow)

99512

Home visit for hemodialysis

99601

Home infusion/specialty drug administration, per visit (up to 2 hours)

NOTE: 90963 – 90966 are reported only once per month and should not be used if a hospitalization occurred during the month. Dialysis treatment (90935, 90937, 90945, and 90947) and non-ESRD services are not included in procedure codes 90963 – 90966 and should be reported separately when appropriate.

HCPCS Coding:

A4206 – A4215

Syringes, needles, saline

A4216

Sterile water, saline and/or dextrose, diluent/flush, 10 ML

A4217

Sterile water/saline, 500 ml

A4300

Implantable access catheter, peritoneal

A4338

Indwelling catheter; Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer, OR hydrophilic, etc.), each

A4346

Indwelling catheter; Foley type, three-way for continuous irrigation, each

A4649

Surgical supply; miscellaneous

A4651

Calibrated microcapillary tube, each

A4652

Microcapillary tube sealant

A4653

Peritoneal dialysis catheter anchoring device, belt, each

A4657

Syringe, with OR without needle, for dialysis, each

A4671

Disposable cycler set used with cycler dialysis machine, each

A4672

Drainage extension line, sterile, for dialysis, each

A4673

Extension line with easy lock connectors, used with dialysis

A4674

Chemicals/antiseptics solution used to clean/sterilize dialysis equipment, per 8 oz

A4680

Activated carbon filters for dialysis

A4690

Dialyzers (artificial kidneys) all brands, all sizes per unit

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

A4714

Treated water (deionized, distilled, reverse osmosis) for use in dialysis

A4719

“Y set” tubing for peritoneal dialysis

A4720

Dialysate solution, any concentration of dextrose, fluid volume 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

A4728

Dialysate solution, non-dextrose containing, 500 ml

A4730

Fistula cannulation set for dialysis only

A4736

Topical anesthetic, for dialysis, per gram

A4737

Injectable anesthetic, for dialysis, per 10 ml

A4740

Shunt accessories for dialysis only

A4750

Blood tubing, arterial OR venous, each

A4755

Blood tubing, arterial and venous combined

A4760

Dialysate standard testing solution, supplies

A4765

Dialysate concentrate additives, each

A4766

Dialysate concentrate, solution, additive for peritoneal dialysis, per 10 ml

A4770

Blood testing supplies (e.g., vacutainers and tubes)

A4771

Serum clotting time tube, per box

A4772

Dextrostick OR glucose test strips, per box

A4773

Hemostix, per bottle

A4774

Ammonia test paper, per box

A4802

Protamine sulfate, for hemodialysis, per 50 mg

A4860

Disposable catheter caps

A4870

Plumbing AND/OR electrical work for home dialysis equipment

A4890

Contracts, repair and maintenance, for hemodialysis equipment (non-covered)

A4911

Drainage bag/bottle, for dialysis, each

A4913

Miscellaneous dialysis supplies, not otherwise specified

A4918

Venous pressure clamps, for hemodialysis, each

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, flow rate meter, power off, heater and temp control with alarm, IV poles, pressure gauge, concentrate container

E1520

Heparin infusion for dialysis

E1530

Air bubble detector for dialysis

E1540

Pressure alarm for dialysis

E1550

Bath conductivity meter for dialysis

E1560

Blood leak detector for dialysis

E1570

Adjustable chair, for ESRD patients

E1575

Transducer protectors/fluid barriers, any size, each

E1580

Unipuncture control system for dialysis

E1590

Hemodialysis machine

E1595

Automatic intermittent peritoneal dialysis system

E1594

Cycler dialysis machine for peritoneal dialysis

E1600

Delivery AND/OR installation charges for renal dialysis equipment

E1610

Reverse osmosis water purification system

E1615

Deionizer water purification system

E1620

Blood pump for dialysis

E1625

Water softening system

E1630

Reciprocating peritoneal dialysis system

E1632

Wearable artificial kidney

E1634

Peritoneal dialysis clamps, each

E1635

Compact (portable) travel hemodialyzer system

E1636

Sorbent cartridges, per case

E1637

Hemostats

E1699

Dialysis equipment, unspecified, by report

J1644

Injection, heparin sodium, per 1000 units

J7030

Infusion, normal saline solution, 1000 cc

J7040

Infusion, normal saline solution, sterile (500 ml = 1 unit)

J7042

5% dextrose/normal saline (500 ml = 1 unit)

J7050

Infusion, normal saline solution, 250 cc

J7060

5% dextrose/water (500 ml = 1 unit)

J7070

Infusion, D-5-W, 1,000 cc

S9335

Home therapy, hemodialysis; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing services coded separately), per diem

S9339

Home therapy, peritoneal dialysis; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing services coded separately), per diem

ICD-9 Diagnoses Codes That Support Medical Necessity:

585.6

End stage renal disease (ESRD)

ICD-10 Diagnoses Codes That Support Medical Necessity (Effective 10/01/15):

N18.6, N18.7

End stage renal disease

REIMBURSEMENT INFORMATION:

Reimbursement for ESRD related services per day (90922 – 90925) is based on 30 days within any calendar month, regardless of the actual number of days in any given month or the number of providers.

Reimbursement for 90922 – 90925 is based on 1/30th of the full month ESRD services (90918 – 90921).

Repairs and maintenance for rented dialysis equipment are included in the rental allowance. Repairs and maintenance of purchased dialysis equipment are covered and reimbursed separately.

Repair and maintenance (A4890) contracts (i.e., fees paid in anticipation of the need for service) are included in the allowances for the equipment.

For additional reimbursement information of specific services, see POSITION STATEMENT above.

For Medicare Advantage members, please contact Membership and Billing for notification of patient ESRD status.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

Non-medical Necessity Coverage and Payment Rules for Home Dialysis supplies and equipment:

  1. 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.
  2. Claims for tape (A4450, A4452) that are billed without an AX modifier or another modifier indicating coverage under a different policy will be denied as non-covered.
  3. Claims for selected supplies and equipment used for home dialysis (A4215, A4244, A4245, A4246, A4247, A4248, A4651, A4652, A4657, A4660, A4663, A4670, A4927, A4928, A4930, A4931, A6250, A6260, E0210, E1632, E1637, E1639 and J1644) that are billed without an AX modifier will be denied as noncovered.
  4. 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 once in a lifetime allowance for each dialysis modality (hemodialysis, continuous ambulatory peritoneal dialysis and continuous cycling peritoneal dialysis) that the patient receives. For a single modality, only emergency reserve supplies provided in the same calendar month will be covered. 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.
  5. The allowance per month under Method II for home dialysis supplies and equipment 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.

In order to cover intradialytic parenteral nutrition (IDPN), documentation must be clear and precise to verify that the patient suffers from a permanently impaired gastrointestinal tract and that there is insufficient absorption of nutrients to maintain adequate strength and weight. Records should document that the patient cannot be maintained on oral or enteral feedings and that due to severe pathology of the alimentary tract, the patient must be intravenously infused with nutrients. Infusions must be vital to the nutritional stability of the patient and not supplemental to a deficient diet or deficiencies caused by dialysis. Physical signs, symptoms and test results indicating severe pathology of the alimentary tract must be clearly evident in any documentation submitted. Patients receiving IDPN must meet parenteral nutrition coverage criteria.

DEFINITIONS:

No guideline specific definitions apply.

OTHER:

None applicable.

REFERENCES:

  1. American Medical Association CPT (current edition).
  2. American Society of Nephrology, Important Facts About Dialysis, accessed 08/01/07.
  3. Blue Cross Blue Shield Association Medical Policy Reference Manual, Daily Hemodialysis in the Home, (8.02.05), 06/12/08.
  4. Brenner & Rector's The Kidney, 6th ed., Copyright © 2000 W. B. Saunders Company.
  5. Centers for Medicare & Medicaid Services Region C DMERC Local Coverage Determination and Coding Article for Home Dialysis Supplies and Equipment (L5000) (revision effective date 09/01/09).
  6. Centers for Medicare & Medicaid Services Region C DMERC Local Coverage Determination and Coding Article for Parenteral Nutrition (L11561), 10/01/09.
  7. Centers for Medicare & Medicaid Services, NCD for Peridex CAPD Filter Set (230.13), 05/01/09.
  8. Centers for Medicare & Medicaid Services, NCD for Ultra filtration Monitor (230.14) 07/11/83.
  9. Centers for Medicare & Medicaid Services, NCD for Water Purification and Softening Systems Used in Conjunction with Home Dialysis (230.7), 05/89.
  10. ECRI Institute, Home Dialysis May Significantly Improve Quality of Life While Potentially Lowering Costs, 06/05.
  11. Goldman: Cecil Textbook of Medicine, 21st ed., Copyright © 2000 W. B. Saunders Company.
  12. Hayes, Inc., Portable Hemodialysis for Treatment of Renal Failure, 02/07.
  13. Medicare Coverage Issues Manual (CIM 35-51, 55-1, 55-2, 55-3).
  14. St. Anthony’s ICD-9-CM Code Book 2001, (current edition).

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 10/22/09.

GUIDELINE UPDATE INFORMATION:

01/01/02

MCG Reformatted / HCPCS coding changes.

01/01/03

Annual HCPCS coding update.

03/15/03

Reviewed – no coverage changes.

07/01/03

HCPCS coding update (added K0610 – K0614).

10/01/03

4th Quarter HCPCS coding update (deleted K0610 – K0614).

01/01/04

Annual HCPCS coding update.

03/15/04

Scheduled reviewed; removed investigational statement for IDPN/IPN; added statement regarding hemodialysis for treating schizophrenia; added clarification for coverage of repairs and maintenance services; updated coding information; formatting changes. Also added the word Home to the title.

01/01/06

Annual HCPCS coding update: deleted A4656 and 90939; revised code descriptor for 90940.

01/01/07

Annual HCPCS coding update: revised A4216 code description.

09/15/07

Review, coverage statements maintained, Medicare Advantage products section updated, guideline reformatted, references updated.

01/01/09

Annual HCPCS coding update: removed 90918 – 90925, 90935, 90937, 90939, and 90940. Added 90963, 90964, 90965, 90966, 90967, 90968, 90970, 99512, and 99601; and corrected 90997.

11/15/09

Revisions consisting of updates to the reimbursement guidelines for supplies; Medicare Program Exception reimbursement criteria for supplies and additional codes (J1644, S9335, and S9338) were added; references updated.

10/15/10

Revision; related ICD-10 codes added.

09/15/11

Revision; formatting changes.

05/11/14

Revision: Program Exceptions section updated.

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is copyright 2013, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2013 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

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Date Printed: October 25, 2014: 01:25 PM