CMS Pub. 100-04, ch. 4, § 200.2

Stage Renal Disease (ESRD)

(Rev. 2455, Issued: 04-26-12, Effective: 10-01-12, Implementation; 10-01-12)

Effective with claims with dates of service on or after August 1, 2000, hospital-based End

Stage Renal Disease (ESRD) facilities must submit services covered under the ESRD

benefit in 42 CFR 413.174 (maintenance dialysis and those items and services directly

related to dialysis such as drugs, supplies) on a separate claim from services not covered

under the ESRD benefit. Items and services not covered under the ESRD benefit must be

billed by the hospital using the hospital bill type and be paid under the Outpatient

Prospective Payment System (OPPS) (or to a CAH at reasonable cost). Services covered

under the ESRD benefit in 42 CFR 413.174 must be billed on the ESRD bill type and

must be paid under the ESRD PPS. This requirement is necessary to properly pay only

unrelated ESRD services (those not covered under the ESRD benefit) under OPPS (or to

a CAH at reasonable cost).

Medicare does not allow payment for routine or related dialysis treatments, which are

covered and paid under the ESRD PPS, when furnished to ESRD patients in the

outpatient department of a hospital. However, in certain medical situations in which the

ESRD outpatient cannot obtain her or his regularly scheduled dialysis treatment at a

certified ESRD facility, the OPPS rule for 2003 allows payment for non-routine dialysis

treatments (which are not covered under the ESRD benefit) furnished to ESRD

outpatients in the outpatient department of a hospital. Payment for unscheduled dialysis

furnished to ESRD outpatients and paid under the OPPS is limited to the following

circumstances:

• Dialysis performed following or in connection with a dialysis-related procedure

such as vascular access procedure or blood transfusions;

• Dialysis performed following treatment for an unrelated medical emergency; e.g.,

if a patient goes to the emergency room for chest pains and misses a regularly

scheduled dialysis treatment that cannot be rescheduled, CMS allows the hospital

to provide and bill Medicare for the dialysis treatment; or

• Emergency dialysis for ESRD patients who would otherwise have to be admitted

as inpatients in order for the hospital to receive payment.

In these situations, non-ESRD certified hospital outpatient facilities are to bill Medicare

using the Healthcare Common Procedure Coding System (HCPCS) code G0257

(Unscheduled or emergency dialysis treatment for an ESRD patient in a hospital

outpatient department that is not certified as an ESRD facility).

HCPCS code G0257 may only be reported on type of bill 13X (hospital outpatient

service) or type of bill 85X (critical access hospital) because HCPCS code G0257 only

reports services for hospital outpatients with ESRD and only these bill types are used to

report services to hospital outpatients. Effective for services on and after October 1,

2012, claims containing HCPCS code G0257 will be returned to the provider for

correction if G0257 is reported with a type of bill other than 13X or 85X (such as a 12x

inpatient claim).

HCPCS code 90935 (Hemodialysis procedure with single physician evaluation) may be

reported and paid only if one of the following two conditions is met:

1) The patient is a hospital inpatient with or without ESRD and has no coverage

under Part A, but has Part B coverage. The charge for hemodialysis is a charge

for the use of a prosthetic device. See Benefits Policy Manual 100-02 Chapter 15

section 120. A. The service must be reported on a type of bill 12X or type of bill

85X. See the Benefits Policy Manual 100-02 Chapter 6 section 10 (Medical and

Other Health Services Furnished to Inpatients of Participating Hospitals) for the

criteria that must be met for services to be paid when a hospital inpatient has Part

B coverage but does not have coverage under Part A; or

2) A hospital outpatient does not have ESRD and is receiving hemodialysis in the

hospital outpatient department. The service is reported on a type of bill 13X or

type of bill 85X.

CPT code 90945 (Dialysis procedure other than hemodialysis (e.g. peritoneal dialysis,

hemofiltration, or other continuous replacement therapies)), with single physician

evaluation, may be reported by a hospital paid under the OPPS or CAH method I or

method II on type of bill 12X, 13X or 85X.