Rule 5160-4-14 | Professional services associated with dialysis.
(A) Routine maintenance dialysis.
(1) Payment for professional services associated with the medical management of patients receiving maintenance dialysis is made either on a monthly capitation basis or on a daily basis.
(a) The monthly capitation payment is available to a single practitioner in the following circumstances:
(i) The practitioner alone provides monthly continuity of services to a single patient or to a group of patients; or
(ii) The practitioner serves as the primary practitioner in a joint provision (in which one person receives payment on behalf of a team of practitioners).
(b) When dialysis care is provided by more than one practitioner in the absence of a joint provision, payment may be made to each practitioner separately for the days on which dialysis care was provided.
(c) On a submitted claim, the type of service payment (monthly capitation or daily care) is differentiated by procedure code.
(2) In addition to the payment for professional services, separate payment may be made for the following services:
(a) The declotting of shunts; and
(b) Covered professional services that are unrelated to the patient's dialysis or renal condition.
(B) Inpatient dialysis services.
(1) Payment may be made for professional services that are related to dialysis performed for a hospital inpatient for one of the following reasons:
(a) Treatment of acute renal failure or renal trauma;
(b) Establishment of an initial course of dialysis (the first dialysis treatment and all subsequent dialysis treatments performed before the patient is stabilized on dialysis); or
(c) Treatment of an established dialysis patient who was admitted to the hospital for a condition or illness unrelated to the patient's renal condition.
(2) The following provisions apply to payment for professional services related to inpatient dialysis:
(a) The time when the practitioner is present with the patient during the dialysis procedure is documented in the patient's medical record.
(b) On a submitted claim, an appropriate procedure code is used to indicate inpatient dialysis care.
(c) Payment for professional services includes all evaluation and management services related to the patient's renal condition. (The payment to the hospital for inpatient dialysis includes all other patient care services that are rendered during the dialysis procedure.)
(d) If a dialysis patient is admitted to a hospital for no reason other than to receive maintenance dialysis, the dialysis is considered to be routine maintenance and payment for professional services is made accordingly.
(C) For services rendered to a single patient in a single calendar month, the following overpayments or duplicate payments are disallowed:
(1) More than one monthly capitation payment;
(2) Payment for more than thirty-one days of daily dialysis care; and
(3) Both the monthly capitation payment and payment for daily dialysis care.
Last updated July 1, 2021 at 9:53 AM
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