LCD : Dialysis Frequency (L13302)

LCD for Dialysis Frequency (L13302)

Contractor Information

Contractor Name ^{back to top}
BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)
Contractor Number ^{back to top}
00390
Contractor Type ^{back to top}
FI

LCD Information

LCD ID Number ^{back to top}
L13302

LCD Title ^{back to top}
Dialysis Frequency

Contractor's Determination Number ^{back to top}
L13302

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. � 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy ^{back to top}
Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section excludes coverage of items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations. Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim. Code of Federal Regulations (CFR) Part 413 Subpart H. This section addresses payment for ESRD Services. Medicare Renal Dialysis Facility Manual CMS Provider Reimbursement Manual

Primary Geographic Jurisdiction ^{back to top}
New Jersey Tennessee

Secondary Geographic Jurisdiction ^{back to top}
Alaska Alabama Arkansas Arizona California Colorado Connecticut Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi North Carolina North Dakota Nebraska New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

Oversight Region ^{back to top}
Region IV


Original Determination Effective Date ^{back to top}
For services performed on or after 09/30/2003

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 12/14/2005

Revision Ending Date ^{back to top}


Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
End-Stage Renal Disease (ESRD) program of Medicare was established by the Social Security Amendments of 1972 (Public Law 92-603). This law extended Medicare coverage to individuals who have permanent kidney failure, requiring either dialysis or transplantation, and who meet other eligibility requirements. This LCD is intended to define the conditions for which additional dialysis, beyond three sessions per week, is reasonable and medically necessary. Most End Stage Renal Disease Patients are treated with dialysis, which involves the clearing of toxins from the blood through a semi-permeable membrane or dialyzer. There are basically two dialysis modalities: (1) hemodialysis (HD), where blood passes through an artificial kidney, waste products diffuse across the semi-permeable membrane into a bath solution known as the dialysate, and the cleansed blood is returned to the patient; (2) peritoneal dialysis (PD), where the peritoneal membrane in the abdominal cavity is used as the dialyzer and filtration of toxins occurs through exchanges of dialysate fluid in the peritoneal cavity via an indwelling catheter. PD is generally performed at home, with or without machine assistance (i.e., continuous cycling peritoneal dialysis (CCPD) and continuous ambulatory peritoneal dialysis (CAPD), respectively). A third type of PD, nocturnal intermittent peritoneal dialysis (NIPD), is also a machine aided form of this modality, but performed while the patient sleeps. Hemodialysis is typically furnished three times per week in sessions of 4 to 5 hours duration[CMS Pub 100-1, 5-�20.1]. Peritoneal Dialysis is usually done in sessions of 10-12 hours duration 3 times per week. RGBA will consider hemodialysis and peritoneal dialysis performed more than three times per week reasonable and medically necessary for the following indications: Inadequate dialysis � Inadequate dialysis evidenced by low Kt/V or URR level (Kt/V below 1.2 or URR <65%) as a result of: Poor HD access resulting to below prescribed blood flow rate (BFR) Clinical events resulting to chronic premature discontinuation of dialysis treatments. (e.g. persistent unmanageable hypotension, chest pains or muscle cramps inspite of therapeutic efforts with volume expanders, hypertonic solutions, etc.) Malfunctioning PD indwelling catheter and/or presence of an infectious process. Respiratory distress - Extra dialysis sessions may be necessary if the patient is exhibiting signs and symptoms of respiratory distress due to fluid overload, evidenced by: Interdialytic weight gain in excess of five pounds accompanied by shortness of breath, labored breathing, wet lung sounds or cyanosis; Absence of excessive weight gain but with presenting symptoms of shortness of breath, labored breathing, wet lung sounds or cyanosis; Congestive heart failure with marked pulmonary edema as evidenced by blood gases (hypoxemia) and/or chest X-ray Hyperkalemia - An extra session may be necessary for potassium levels greater than 6 meq per liter Acute pericarditis Complications of Pregnancy Reasons for extra dialysis treatment(s) other than listed above should be clearly documented, such as: Equipment problems; Dialyzer blood leak; Inefficient dialyzer surface area; Inadequate performance of reprocessed dialyzers; Dialyzer clotting; Procedural errors by staff e.g. errors in BFR, DFR (dialysate flow rate) and TMP (transmembrane pressure) settings, etc.; Less than prescribed dialysis treatment hours d/t late patient arrival or late dialysis treatment start times or patient request for early termination of treatments for reasons other than clinical events; And all other justifications for extra dialysis treatment(s) rendered. Standing orders for extra HD treatment should be supported with physician�s monthly assessment and evaluation of the continued need for dialysis session(s) greater than 3x per week, accompanied by tests reports, consultation reports and other pertinent supporting documents. If the patient is regularly receiving less than 4 hours of dialysis a session, extra dialysis treatments must be supported by documentation showing why the same outcome cannot be achieved by increasing the numbers of hours per session. When extended peritoneal dialysis of 20-29 hours or 30 hours or more is needed more frequently than once per week, additional medical evidence must be submitted to and accepted by this intermediary before additional payment can be made [CMS Pub 100-4, 8�30]. In instances where a combination of dialysis techniques (HD and PD) is required in order to achieve satisfactory results, Medicare will pay for both types of dialysis when use of back-up dialysis is supported with documentation of medical necessity. If back-up sessions are frequently required, determination of whether CAPD is appropriate mode of treatment should be determined [PRM 2709.2]. Ultrafiltration is a process of removing excess fluid from the blood through the dialysis membrane and is used in cases where excess fluid cannot be removed easily during the regular course of hemodialysis. Ultrafiltration is commonly done during the first hour or two of hemodialysis on patients. Coverage of ultrafiltration rendered other than the time when a dialysis treatment is given must have documentation of why the ultrafiltration could not have been performed at the time of the dialysis treatment [PRM 2702.2]. In general, any dialysis session(s) beyond 3 times per week will be non-covered unless documentation of medical necessity is clearly stated and is evident in test reports and other supporting documents. An extra dialysis session will not be considered medically necessary when either the preceeding session, the extra session or the subsequent session is less than 4 hours duration unless specific documentation is provided addressing either the medical inability to substitute longer sessions or the medical need for an abbreviated session. Reasons for Denial If the documentation supplied by the facility does not support the need for the services, or the facility fails to submit the requested documentation, the services will be denied [MIM 3907.1]. Service rendered does not follow the guidelines of this policy

Coverage Topic ^{back to top}
Dialysis (Kidney) Outpatient

Coding Information

Bill Type Codes: ^{back
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Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes: ^{back
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Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

082X	Hemodialysis OP or home dialysis-general classification
083X	Peritoneal dialysis OP or home-general classification
084X	CAPD outpatient-general classification
085X	CCPD outpatient-general classification

CPT/HCPCS Codes ^{back
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90999

UNLISTED DIALYSIS PROCEDURE, INPATIENT OR OUTPATIENT

ICD-9 Codes that Support Medical Necessity ^{back
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276.7	HYPERPOTASSEMIA
420.0	ACUTE PERICARDITIS IN DISEASES CLASSIFIED ELSEWHERE
518.4	ACUTE EDEMA OF LUNG UNSPECIFIED
586	RENAL FAILURE UNSPECIFIED
646.90	UNSPECIFIED COMPLICATION OF PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE
786.02	ORTHOPNEA
786.05	SHORTNESS OF BREATH
786.06	TACHYPNEA
786.09	RESPIRATORY ABNORMALITY OTHER
786.7	ABNORMAL CHEST SOUNDS
788.9	OTHER SYMPTOMS INVOLVING URINARY SYSTEM
V23.89	SUPERVISION OF OTHER HIGH-RISK PREGNANCY

Diagnoses that Support Medical Necessity ^{back
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ICD-9 Codes that DO NOT Support Medical Necessity ^{back
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ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back
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Diagnoses that DO NOT Support Medical Necessity ^{back
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General Information

Documentation Requirements ^{back
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All justifications to support medical necessity of any additional dialysis sessions greater than 3x per week must be clearly indicated/documented in the patient's medical record and available for review upon request. The documents should include:

Physician�s orders
Physician�s evaluation and progress notes
Dialysis flowsheets and nurses notes
Pertinent laboratory/radiology tests
Pertinent Consultation notes
History and Physical

Appendices ^{back
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LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:
Frequently Asked Questions

Utilization Guidelines ^{back
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Sources of Information and Basis for Decision ^{back
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Other contractor�s policy (Trailblazer Health Enterprises)

Guidelines for Hemodialysis Adequacy. National Kidney Foundation K/DOQI Guidelines 2000.

CMS Provider Reimbursement Manual

Medicare Carrier Manual

Medicare Renal Dialysis Facility Manual

Medicare Intermediary Manual

Advisory Committee Meeting Notes ^{back
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Public Open Meeting to discuss the draft policy was held 07/24/2003.

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from appropriate specialties as well as provider (facility) representatives.