CMS Pub. 100-04, ch. 8, § 160.4

A. General

When paying for physicians’ services furnished to dialysis inpatients, whether they are

ESRD patients or acute dialysis patients, there are several factors to consider.

• The payment must be for covered physicians’ services;

• The services must be medically necessary; and

• The payment for the services must be reasonably related to the nature of the

services actually furnished.

B. Physicians’ Services - Criteria for Procedure Codes

The procedure code covers the full range of physicians’ renal-related services furnished

during an inpatient dialysis treatment.

In order to be paid on the basis of a procedure code, the physician must have been

physically present with the patient at some time during the course of the dialysis, and the

medical record (e.g., the physician’s progress note or the nurse’s notes in the patient’s

hospital medical record) must document this.

If the physician visits the dialysis inpatient on a dialysis day, but not during the dialysis

treatment, do not pay the physician on the basis of a procedure code. The nature of these

services is the same as physicians’ services furnished to any inpatient during a hospital

visit. Therefore, use the same hospital visit codes that apply to any other physicians

treating hospital inpatients.

Physicians’ services furnished to patients who are dialyzed as inpatients because there is

no room in the outpatient dialysis units are covered under the MCP, and physicians are

not paid amounts in addition to or in place of the MCP.

Effective January 1, 1995, all evaluation and management services provided on the same

day as inpatient dialysis codes should be denied without review with the exception of

CPT codes 99221-99223, 99251-99255, and 99238. These codes may be billed with

modifier “-25” and reviewed for possible allowance if the evaluation and management

service is unrelated to the treatment of ESRD and was not and could not have been

furnished during the dialysis treatment.

C. Peritoneal Dialysis

Peritoneal dialysis is typically furnished in extended periods. For example, CAPD is

continuous, and the patient may actually be dialyzed seven days per week. IPD may be

furnished in extended periods of 30 hours or more. The fact that a patient is dialyzed

continuously for an extended period does not justify payment in excess of the average

weekly allowance made for hemodialysis services. Payment in excess of this amount is

made only if it is determined that the same kind and intensity of physicians’ hemodialysis

treatment beyond the number ordinarily furnished in a 7-day period, and the patient’s

condition was similar to that of a hemodialysis patient who would have required these

additional services.