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.

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 (90918-90925, G0308-G0327)
Home hemodialysis care (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, hook-up, transcutaneous measurement and disconnection (90939, 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.

Self-dialysis and staff-assisted dialysis sessions are not covered services. However, monthly maintenance care (90918-90925, G0308-G0327) is covered.

PRN References

12/1997, Fees and policy changes for certain hemodialysis procedures