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Current Issues with ESRD and Dialysis billing

July 31, 2018

Dialysis Billing

Dialysis is the procedure for removing bodily wastes when the kidneys’ functions are impaired and unable to do so. This takes place by diffusing from one fluid compartment to another across a semi-permeable membrane, and which can include hemodialysis, peritoneal dialysis, ultrafiltration and hemofiltration.

Out of these procedures, two – hemodialysis and peritoneal dialysis – are the ones commonly used for treating End Stage Renal Disease (ESRD).

Hemodialysis – Blood is passed through an artificial kidney machine, with wastes diffused across a membrane into a cleansing solution called dialysate, after which the cleansed blood is returned to the patient’s body. This process is usually performed 2-3 times weekly, with each session lasting three to five hours.

Peritoneal dialysis (PD) – The patient’s waste is passed from the body through the peritoneal directly into the (abdominal) peritoneal cavity where a dialysate cleansing solution is introduced then periodically removed.

It is particularly suitable for children and patients lacking caregivers for help in self-dialysis.

New Developments in Dialysis and ESRD Treatment

Dialysis and End Stage Renal Disease (ESRD) have undergone a number of important changes over the few years, particularly regarding ESRD reimbursement billing as a reflection of improvements in treatment, the increase in dialysis centers as well as an increase in home dialysis as an additional cost-saving measure.

Some of the new developments include

  • Increasing in-hospital transfusions
  • Shifts in overall medication usage
  • Bundling payments, also known as “consolidated billing”
  • The introduction of newer medications
  • An uptick in home dialysis as a response to more patient-friendly, cost-reducing options

For the sake of brevity, we’ll focus on the billing implications of bundling as well as the impact of home dialysis on centers and their billing staff.

Bundling Payments and its Effects on Dialysis Billing

Since it was introduced by the federal government (CMS) in January, 2011, bundling has created a new awareness among providers and back office alike about cost-consciousness, in how resources, especially medications, are used on patients with ESRD. Providers of dialysis were being challenged to reduce and control costs while maintaining high levels of care quality.

One major effect of bundling was turning medications from cost centers versus profit centers, according to Wake Forest University Medical Center’s John Burkhart, M.D., who oversees the university’s outpatient dialysis center. As a result of facing fixed payments, providers were taking a closer look at a given medicine’s benefits, questioning whether higher lab metrics made clinical differences that were meaningful in outcomes.

CMS and Dialysis Billing Requirements and Bundling

  • For clinics which bill under the Prospective Payment System (PPS), for example, they would bill Medicare at its usual hemodialysis rate plus training add-on if the patient needs to be retrained after the first 4 months of services.
  • The PPS adjustment that was applied (by the Medicare administrative contractors or MACs) is only to be applied the first time the patient undergoes dialysis. It is not applied a subsequent time should the patient resume treatment, for example, following a transplant that failed.
  • One point to remember regarding billing Medicare for dialysis is that, depending on modality, Medicare can be billed for a certain number of training sessions (see their Claims Processing Manual  for information). The clinic overseeing the training and related services must be certified for providing home training and support.

The following are the usual circumstances under which Medicare would pay:

  • Continuous Ambulatory Peritoneal Dialysis (CAPD) – Medicare allows up to 15 training sessions based on a five-session week, with each lasting up to eight hours.
  • Continuous Cycling Peritoneal Dialysis (CCPD – Medicare allows up to five per-day exchanges for five to six days per week.
  • Home hemodialysis – Medicare normally pays up to two months of training based on three five-hour training sessions per week.

Consult the latest edition of your Medicare Claims Processing Manual for guidelines for aiding the dialysis and renal care billing process.

Home Dialysis Gains Ground

Closely linked to the introduction of bundling is an uptick of renal-replacement therapy patients

starting treatment with peritoneal dialysis instead of in-center dialysis. Prior to bundling, there were a greater number of hemodialysis patients and the use of IV medications as revenue sources; this has dropped due to IV now being a bundled charge, as well as increased risk- transfer to physicians.

Read More: Specialty-Specific Medical Billing Service Advantages

For those practices that don’t have time or personnel to spare attending training seminars or other means of keeping staff updated, one good solution is to outsource the billing altogether to a billing service experienced in accurately billing for dialysis services in a timely manner.

Why Use a Specialized Billing Service?

One mistake that some practices make when outsourcing dialysis billing is to contract with a company lacking experience and understanding of the significance of the codes and modifiers applicable to various treatment modalities and conditions. As we’ve already seen above, these can be fairly complex, so this is not work to be handed off to a “general” billing service or an inexperienced billing staffer.

Since 2002, M-Scribe has been helping nephrology practices and dialysis centers improve reimbursement through familiarity with the terminology and procedures performed. Equally important is the ability to effectively appeal any denied claims, respond to insurance payers’ questions and handle complex dialysis pre-authorizations.

In addition, a quality billing service such as M-Scribe has the ability to track underpayments with state of the art software and other technologies, as well as our experienced, trained professionals.
Finally, assistance with collections is essential to full reimbursement, as EOBs for dialysis can be more complex and confusing to patients as well as the size of the amounts that may be owed.  Contact M-Scribe at 770-666-0470 or email for a free analysis of your practice’s revenue cycle needs.


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