CMS Pub. 100-03, ch. 1, § 110.15

CIM 35-38

A. Ultrafiltration

This is a process for removing excess fluid from the blood through the dialysis membrane by means of

pressure. It is not a substitute for dialysis. Ultrafiltration is utilized in cases where excess fluid cannot be

removed easily during the regular course of hemodialysis. When it is performed, it is commonly done

during the first hour or two of each hemodialysis on patients who, e.g., have refractory edema.

Ultrafiltration is a covered procedure under the Medicare program (effective for services performed on and

after September 1, 1979)

Predialysis Ultrafiltration

While this procedure requires additional staff care, the facility dialysis rate is intended to cover the full range

of complicated and uncomplicated nonacute dialysis treatments. Therefore, no additional facility charge is

recognized for predialysis ultrafiltration. The physician’s role in ultrafiltration varies with the stability of

the patient’s condition. In unstable patients, the physician may need to be present at the initiation of

dialysis, and available either in-house or in close proximity to monitor the patient carefully. In patients who

are relatively stable, but who seem to accumulate excessive weight gain, the procedure requires only a

modest increase in physician involvement over routine outpatient hemodialysis.

Occasionally, medical complications may occur which require that ultrafiltration be performed separate

from the dialysis treatment, and in these cases an additional charge can be recognized. However, the claim

must be documented as to why the ultrafiltration could not have been performed at the same time as the

dialysis.

B. Hemoperfusion

This is a process which removes substances from the blood using a charcoal or resin artificial kidney. When

used in the treatment of life threatening drug overdose, hemoperfusion is a covered service for patients with

or without renal failure. Hemoperfusion generally requires a physician to be present to initiate treatment and

to be present in the hospital or an adjacent medical office during the entire procedure, as changes may be

sudden. Special staff training and equipment are required.

Develop charges for hemoperfusion in the same manner as for any new or unusual service. One or two

treatments are usually all that is necessary to remove the toxic compound; document additional treatments.

Hemoperfusion may be performed concurrently with dialysis, and in those cases payment for the

hemoperfusion reflects only the additional care rendered over and above the care given with dialysis.

The effects of using hemoperfusion to improve the results of chronic hemodialysis are not known.

Therefore, hemoperfusion is not a covered service when used to improve the results of hemodialysis. In

addition, it has not been demonstrated that the use of hemoperfusion in conjunction with deferoxamine

(DFO), in treating symptomatic patients with iron overload, is efficacious. There is also a paucity of data

regarding its efficacy in treating asymptomatic patients with iron overload. Therefore, hemoperfusion used

in conjunction with DFO in treating patients with iron overload is not a covered service; i.e., it is not

considered reasonable and necessary within the meaning of §1862(a)(1) of the Act.

However, the use of hemoperfusion in conjunction with DFO for the treatment of patients with aluminum

toxicity has been demonstrated to be clinically efficacious and is therefore regarded as a covered service.

C. Hemofiltration

This is a process which removes fluid, electrolytes and other low molecular weight toxic substances from

the blood by filtration through hollow artificial membranes and may be routinely performed in 3 weekly

sessions. Hemofiltration (which is also known as diafiltration) is a covered procedure under Medicare and is

a safe and effective technique for the treatment of ESRD patients and an alternative to peritoneal dialysis

and hemodialysis. In contrast to both hemodialysis and peritoneal dialysis treatments which eliminate

dissolved substances via diffusion across semipermeable membranes, hemofiltration mimics the filtration

process of the normal kidney. The technique requires an arteriovenous access. Hemofiltration may be

performed either in facility or at home.

The procedure is most advantageous when applied to high-risk unstable patients, such as older patients with

cardiovascular diseases or diabetes, because there are fewer side effects such as hypotension, hypertension

or volume overload.