CMS Clarifies ESRD-related Services Monthly Capitation

Effective Jan. 1, 2011, Medicare contractors will pay for home dialysis monthly capitation payment (MCP) services even when a qualified practitioner other than the MCP physician or practitioner furnishes the required face-to-face visit(s).

This policy change is retroactive, but contractors will not automatically adjust claims already processed. Providers should bring affected claims to the attention of their Medicare contractor within the timely filing period to receive proper payment.

A provision of the 2011 Medicare Physician Fee Schedule (MPFS) final rule requires MCP physicians or nonphysician practitioners (NPPs) to furnish at least one face-to-face patient visit per month for home dialysis MCP services, as described by the following CPT® codes:

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

Although the non-MCP physician or NPP providing the face-to-face visit does not require direct supervision from the MCP physician or NPP, he or she must be a partner, an employee of the same group practice, or an employee of the MCP physician or NPP. And it is the physician or NPP who provides the complete assessment, establishes the patient’s plan of care, and provides the ongoing management who should bill the MCP service, using his or her provider identification number (PIN).

The Centers for Medicare & Medicaid Services (CMS) defines a “qualified” nonphysician practitioner (NPP) as a clinical nurse specialist, nurse practitioner or physician’s assistant. Residents, interns, and fellows enrolled in an approved Medicare graduate medical education (GME) program may also perform face-to-face patient visits so long as the teaching MCP physician is present during the visit.

The Centers for Medicare & Medicaid Services (CMS) Transmittal 2269, Change Request (CR)7520, issued Aug. 5, provides more information regarding this change to the Medicare Claims Processing Manual, Pub. 100-04, chapter 8, sec. 140.1.

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