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July 31, 2014

ESRD Monthly Capitation: Claim Submission, Documentation, and Payment

Physicians and practitioners who manage center-based patients on dialysis are paid a monthly capitation rate (MCP) for most outpatient dialysis-related physician services. Key points:

  • Report CPT codes 90951-90962 once per month to distinguish age-specific services performed in an outpatient setting, based on the number of face-to-face visits provided.
  • Report CPT codes 90963-90966 once monthly for home dialysis patients.
  • The physician or practitioner, who provides the complete assessment, establishes the patient's plan of care and provides ongoing management, should be the one who submits a claim for the monthly service.

Submit the following monthly visit CPT codes for patients 20 years of age or older:

  • 90962 – When providing one face-to-face visit per month;
  • 90961 – When providing two to three face-to-face visits per month;
  • 90960 – When providing four or more face-to-face visits per month.

Claim submission:

For purposes of billing for physician and practitioner ESRD-related services:

  • The term 'month' means a calendar month. The first month in which the beneficiary begins dialysis treatment marks the beginning of treatments through the end of the calendar month. Thereafter, the term 'month' refers to a calendar month.
  • In determining the appropriate age for ESRD-related services code, the age of the beneficiary is based on his/her age at the end of the month. The determination of the beneficiary's age is based on his/her age at the end of the month. Visits must be furnished face-to-face by a physician, clinical nurse specialist, nurse practitioner, or physician's assistant.

Visit Documentation Requirements:

  • Visits may be furnished by another physician or practitioner (who is not the MCP physician or practitioner).
  • If the MCP physician or practitioner relies on other physicians or qualified nonphysician practitioners to provide some of the visits during the month:
  • The MCP physician or practitioner does not have to be present when these other physicians or practitioners provide visits.
  • The non-MCP physician or practitioner must be a partner, an employee of the same group practice, or an employee of the MCP physician or practitioner.
  • When another physician or practitioner furnishes some of the visits during the month, the physician who provides the complete assessment, establishes the patient's plan of care, and provides the ongoing management should submit the claim for the MCP service.
  • If a nonphysician practitioner (NPP) performs the complete assessment and establishes the plan of care, the MCP service should be submitted under the PTAN of the clinical nurse specialist, nurse practitioner, or physician's assistant.
  • Residents, interns and fellows
  • Patient visits by residents, interns and fellows enrolled in an approved Medicare graduate medical education (GME) program may be counted towards the MCP visits if the teaching MCP physician is present during the visit.
  •  Patients designated as/admitted into hospital observation status
    • ESRD-related visits furnished to patients in hospital observation status should be counted for purposes of billing the MCP codes. Visits furnished to patients in hospital observation status are included when submitting MCP claims for ESRD-related services.
  •  ESRD-related visits furnished to beneficiaries residing in a Skilled Nursing Facility (SNF)
    • ESRD-related visits furnished to beneficiaries residing in a SNF should be counted for purposes of submitting the MCP codes.
  •  SNF residents admitted as inpatients
    • Inpatient visits are not counted for purposes of the MCP service. If the beneficiary residing in a SNF is admitted to the hospital as an inpatient, submit the appropriate inpatient ESRD visit code.
  •  ESRD-related visits as telehealth services
    • ESRD-related services with 2 or 3 visits per month and ESRD-related services with 4 or more visits per month may be furnished as telehealth services. However, at least one visit per month is required in person to examine the vascular access site. A clinical examination of the vascular access site must be furnished face-to-face (not as a telehealth service) by a physician, nurse practitioner or physician's assistant.

References:

Reviewed: 12.06.22

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