CMS Pub. 100-04, ch. 8, § 140.1

Capitation Payment (Center Based Patients)

(Rev. 2269, Issued: 08-05-11, Effective: 01-01-11, Implementation: 11-07-11)

Physicians and practitioners managing center based patients on dialysis are paid a

monthly rate for most outpatient dialysis-related physician services furnished to a

Medicare ESRD beneficiary. The payment amount varies based on the number of visits

provided within each month and the age of the ESRD beneficiary. Under this

methodology, separate codes are billed for providing one visit per month, two to three

visits per month and four or more visits per month. The lowest payment amount applies

when a physician provides one visit per month; a higher payment is provided for two to

three visits per month. To receive the highest payment amount, a physician or

practitioner would have to provide at least four ESRD-related visits per month. The

MCP is reported once per month for services performed in an outpatient setting that are

related to the patients’ ESRD.

The physician or practitioner who provides the complete assessment, establishes the

patient’s plan of care, and provides the ongoing management is the physician or

practitioner who submits the bill for the monthly service.

a. Month defined.

For purposes of billing for physician and practitioner ESRD related services, the term

‘month’ means a calendar month. The first month the beneficiary begins dialysis

treatments is the date the dialysis treatments begin through the end of the calendar month.

Thereafter, the term ‘month’ refers to a calendar month.

b. Determination of the age of beneficiary.

The beneficiary’s age at the end of the month is the age of the patient for determining the

appropriate age related ESRD-related services code.

c. Qualifying Visits Under the MCP

• General policy.

Visits must be furnished face-to-face by a physician, clinical nurse specialist, nurse

practitioner, or physician’s assistant.

• Visits furnished by another physician or practitioner (who is not the MCP

physician or practitioner).

The MCP physician or practitioner may use other physicians or qualified nonphysician

practitioners to provide some of the visits during the month. The MCP physician or

practitioner does not have to be present when these other physicians or practitioners

provide visits. In this instance, the rules are consistent with the requirements for hospital

split/shared evaluation and management visits. The non-MCP physician or practitioner

must be a partner, an employee of the same group practice, or an employee of the MCP

physician or practitioner. For example, the physician or practitioner furnishing visits

under the MCP may be either a W-2 employee or 1099 independent contractor.

When another physician is used to furnish some of the visits during the month, the

physician who provides the complete assessment, establishes the patient’s plan of care,

and provides the ongoing management should bill for the MCP service.

If the nonphysician practitioner is the practitioner who performs the complete assessment

and establishes the plan of care, then the MCP service should be billed under the PIN of

the clinical nurse specialist, nurse practitioner, or physician assistant.

• Residents, interns and fellows.

Patient visits by residents, interns and fellows enrolled in an approved Medicare graduate

medical education (GME) program may be counted towards the MCP visits if the

teaching MCP physician is present during the visit.

• Patients designated/admitted as hospital observation status.

ESRD-related visits furnished to patients in hospital observation status that occur on or

after January 1, 2005, should be counted for purposes of billing the MCP codes. Visits

furnished to patients in hospital observation status are included when submitting MCP

claims for ESRD-related services.

• ESRD-related visits furnished to beneficiaries residing in a SNF.

ESRD-related visits furnished to beneficiaries residing in a SNF should be counted for

purposes of billing the MCP codes.

• SNF residents admitted as an inpatient.

Inpatient visits are not counted for purposes of the MCP service. If the beneficiary

residing in a SNF is admitted to the hospital as an inpatient, the appropriate inpatient visit

code should be billed.