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Section: Surgery
Number: S-79
Topic: Hemodialysis/Peritoneal Dialysis
Effective Date: January 1, 2009
Issued Date: January 5, 2009
Date Last Reviewed:

General Policy Guidelines

Indications and Limitations of Coverage

Procedure codes 90935 and 90945 (single evaluation) are intended to represent a standard "uncomplicated" dialysis session. The physician visits/evaluates the patient but because of no complications, does not perform any other service for the patient during that dialysis session.

Procedure codes 90937 and 90947 (repeated evaluations, with or without substantial revision of dialysis prescription) are intended to represent a "complicated" dialysis session. The physician may visit the patient several times during a session and may also adjust the dialysis prescription.

Consultations and medical visits provided on the same day as out-patient dialysis procedures (90935-90947) by the same provider or his or her associate are not eligible for separate reimbursement. Payment for such care is included in the allowance for the dialysis procedure with physician evaluation. If the consultations and medical care are for a non-renal condition as documented in the patient's medical records, medical necessity must be determined through a medical review.  Modifier 25 may be reported with medical care (e.g. visits, consults) to identify it as significant and separately identifiable from the other service(s) provided on the same day.  When modifier 25 is reported, the patient’s records must clearly document that separately identifiable medical care was rendered.

When the severity of the renal condition requires the patient to be hospitalized, payment may be made for inpatient consultations and medical visits provided by the same provider or his or her associate on the same day as dialysis services (90935-90947).

Claims for an unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient department that is not an ESRD facility should be processed using code G0257.

CAPD is a method of dialysis performed by the patient. If a hospitalized CAPD patient requires assistance in this self-dialysis technique, it can be provided by hospital staff. Consequently, charges billed by a physician for CAPD sessions regardless of the place of service should be denied. Inpatient medical care rendered on a fee-for-service basis is eligible.

The following services performed in conjunction with dialysis are not covered:

Self-dialysis sessions (no codes)
Staff-assisted dialysis sessions (no codes)
Monthly maintenance care (90951-90970)
Home visit for hemodialysis (99512)
Dialysis training (90989, 90993)
Connecting tube administration set, change by physician (no code)
Catheter site inspection by physician (no code)
Examination by physician for peritonitis (no code)
Physician review of CAPD apparatus and/or technique (no code)
Hemodialysis access flow study to determine blood flow in grafts and arteriovenous fistulae by an indicator dilution method (90940)

Description

Dialysis is a process by which waste products are removed from the body by diffusion from one fluid compartment to another across a semi-permeable membrane. The two types of dialysis commonly in use are:

Hemodialysis

Blood is passed through an artificial kidney machine and the waste products diffuse across a man-made membrane into a bath solution known as dialysate, after which the cleansed blood is returned to the patient's body.

Peritoneal Dialysis

Waste products pass from the patient's body through the peritoneal membrane into the peritoneal (abdominal) cavity where the dialysate is introduced and removed periodically.

A variation of peritoneal dialysis is continuous ambulatory peritoneal dialysis (CAPD), which is a continuous dialysis process using the patient's peritoneal membrane as a dialyzer.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

909359093790940909459094790951
909529095390954909559095690957
909589095990960909619096290963
909649096590966909679096890969
90970909899099399512G0257 

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits or a contract.  Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

View Previous Versions

[Version 005 of S-79]
[Version 004 of S-79]
[Version 003 of S-79]
[Version 002 of S-79]
[Version 001 of S-79]

Table Attachment

Text Attachment

Procedure Code Attachments

Diagnosis Codes

Glossary





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.



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