CMS Pub. 100-04, ch. 8, § 130.1

Patients

(Rev. 1, 10-01-03)

Under the Initial Method (IM), do not pay for physician’s routine professional dialysis

services. Instead, the dialysis facility’s A/B MAC (A) pays the dialysis facility for them

as part of the facility’s composite rate. Physician’s professional services that are not

routine professional dialysis services are billed to the contractor and paid in the same way

as any other Medicare covered physician professional service.

1. For the physician to be paid under the IM, the following requirements must be

met:

All physicians of the facility must choose the IM with respect to all of the patients treated

at the facility and all of the facility’s Method I home dialysis patients. (See §70.1 for a

description of Method I). All of the facility’s physicians must file a written statement

with their A/B MAC (B) and the facility’s A/B MAC (A) to this effect. For example:

The physicians practicing at ________________ dialysis facility are listed

below. The signature of each physician indicates the physician’s election

to be paid for their routine professional dialysis services under the Initial

Method. This election is effective for services furnished beginning with

the second month after the month in which this statement is filed with the

A/B MAC (B) and the facility’s A/B MAC (A).

This written statement must be signed and dated by each physician.

2. The physician may bill the A/B MAC (B) only those physician’s professional

services that are not routine professional dialysis services. (See paragraph 3 below).

The election of the IM is effective for services furnished beginning with the second

calendar month after the month in which all the physicians of a facility elect it. A

physician may terminate the election by written notice to the A/B MAC (B) and to the

facility’s A/B MAC (A) that the physician thereby terminates the IM. If the A/B MAC

(B) and the A/B MAC (A) receive the termination notice on or before November 1, it is

effective the following January 1. If the A/B MAC (B) or the A/B MAC (A) receives it

after November 1, it is effective January 1 of the second year after the calendar year in

which the notice of termination is received. Note that if the IM is terminated by one

physician, it is thereby terminated for all physicians at the same facility with respect to

the patients treated through that facility.

3. Definitions

A. Administrative Services

Physician services that are differentiated from routine professional services and other

physician services. They include supervision, as described in the definition of

“supervision of staff,” are not related directly to the care of an individual patient and are

supportive of the facility as a whole and of benefit to patients in general. Examples of

administrative services include supervision of staff, staff training, participation in staff

conferences and in the management of the facility, and advising staff on the procurement

of supplies.

B. Dialysis Session

The period of time that begins when the patient arrives at the facility and ends when the

patient departs from the facility. In the case of home dialysis, the period begins when the

patient prepares for dialysis and generally ends when the patient is disconnected from the

machine. In this context, a dialysis facility includes only those parts of the building used

as a facility. It does not include any areas used as a physician’s private office.

C. Medical Direction

Routine professional service that entails substantial direct involvement and the physical

presence of the physician in the delivery of services directly to the patient.

D. Routine Professional Services

Physicians’ services furnished during a dialysis session and all services listed under

“Types of routine professional services” that:

• Are personally furnished by a physician to an individual patient.

• Contribute directly to the diagnosis or treatment of an individual patient.

• Ordinarily must be performed by a physician.

E. Supervision of Staff

Administrative services that do not necessarily require the physician to be present at the

dialysis session. It is a general activity primarily concerned with monitoring performance

of and giving guidance to other health care personnel (such as nurses and dialysis

technicians) who deliver services to patients.

F. Types of Routine Professional Services

Routine professional services include at least the following services when medically

appropriate:

• Visits to the patient during dialysis, and in conjunction with review of

laboratory test results,

• Nurses’ notes and any other medical documentation, as a basis for:

o Adjustment of the patient’s medication, diet or the dialysis

procedure;

o Prescription of medical supplies; and

o Evaluation of the patient’s psychosocial status and the

appropriateness of the modality,

o Medical direction of staff in delivering services to a patient during

a dialysis session, and

o Pre-dialysis and post-dialysis examinations or examinations that

could have been furnished on a pre-dialysis or post-dialysis basis.