5160-4-14 Dialysis.

(A) Routine maintenance dialysis.

(1) All physician professional services associated with the medical management of end-stage renal disease (ESRD) patients receiving maintenance dialysis are paid on a monthly capitation payment (MCP) basis.

(2) The following services may be billed in addition to the MCP:

(a) The declotting of shunts; and

(b) Covered physician services which are unrelated to the patient's dialysis or renal condition.

(3) To receive the MCP, the physician must bill the department on the last day of the month using the appropriate CPT (as defined in rule 5101:3-1-19.3 of the Administrative Code) code (90951 to 90966).

(a) Several physicians may form a team to provide the monthly continuity of services to a single patient or to a group of ESRD patients, or a physician in independent practice may make arrangements with an associate to provide the services to his/her ESRD patients when he/she is temporarily unavailable. Such arrangements are referred to as joint provision arrangements. Under a joint provision, each physician may cover for the other and the MCP may be billed by and reimbursed to the primary physician. The primary physician must make arrangements to compensate the other physicians involved in the dialysis care of the patient(s).

(b) When the dialysis care of a patient is provided by more than one physician during a calendar month and there is not a joint provision arrangement between the physicians, the physicians who provided the split services during the month must bill the department separately using the appropriate CPT code (90967 to 90970) for each day the physician was responsible for the patient's care.

(c) For a recipient during a calendar month, the following payments should never be made:

(i) More than one monthly capitation payment (codes 90951 to 90966);

(ii) More than thirty-one days of dialysis care (codes 90967 to 90970); or

(iii) Payment for the MCP and daily dialysis care (any combination of codes 90951 to 90970).

(4) If a dialysis patient is admitted to a hospital for no reason other than to receive maintenance dialysis (e.g., there was no space available in the dialysis unit or the patient was scheduled for extended intermittent peritoneal dialysis), reimbursement for the professional services associated with the dialysis is still considered routine maintenance dialysis and is only reimbursable on a MCP basis.

(B) Inpatient dialysis services.

(1) Except as provided for in paragraph (A)(4) of this rule, physicians may be paid on a fee-for-service (procedure code) basis for physician professional services provided to hospital inpatients. To be eligible for reimbursement on a fee-for-service basis, the physician must be present with the patient some time during the dialysis, the patient's medical records must document that the physician was present, and the dialysis must be performed for one of the following reasons:

(a) For acute renal failure or renal trauma;

(b) As an initial course of dialysis (the "initial course of dialysis" means the first dialysis treatment and all subsequent dialysis treatments performed prior to the patient's stabilization on dialysis); or

(c) For an ESRD patient who was admitted to the hospital for a condition or illness that is unrelated to the patient's renal condition and the physician has elected to bill the inpatient dialysis services on a fee-for-service basis. If the physician has elected to bill the inpatient dialysis services on a fee-for-service basis and the physician usually is paid the MCP, the physician may not bill for the MCP (CPT codes 90951 to 90966) that month and must bill using the appropriate CPT code (90967 to 90970) only for the days the patient was not a hospital inpatient.

(2) For reimbursement for inpatient dialysis services on a fee-for-service basis, the provider must bill the appropriate dialysis code from the range of 90935 to and including 90947.

(3) All evaluation and management services related to the patient's end stage renal disease that are rendered on a day when dialysis is performed and all other patient care services that are rendered during the dialysis procedure are included in the payment for codes 90935 to 90947.

Effective: 03/31/2009
R.C. 119.032 review dates: 03/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
Prior Effective Dates: 9/1/89, 5/25/91, 12/1/92, 12/31/92 (Emer), 4/1/93, 12/29/95 (Emer), 3/21/96, 12/31/08 (Emer)