There are various types of services and procedures that can be included in the CPT code.

There are a few missing words and a lack of understanding that make it difficult to get reimbursement for Parkinson's services.The same cannot be said for commercial and other government payers who provide Medicare Advantage plans.In my experience, there are some outpatients who are not being fully reimbursed for their services.

The article focuses on the problematic wording in the current coding manual and the common misinterpretations that can take place.

Poor wording in the manual starts the reimbursement problems.The manual states that the codes 90935 and 90937 are to be used for inpatient and non-ESRD procedures.

The section immediately after hemodialysis has the CPT codes for PD services.In the section titled, "Miscellaneous Dialysis Procedures", there is a definition of "Dialysis procedure other than hemodialysis."The explanatory paragraph states that the codes should only be used for outpatient non-ESRD care.Without that wording in place, various payers and billers conclude 90945 and 90947 can be used for billing.The centers only bill for the technical components of the procedure, not the physician services.

There are separate bills for hospital and office visits, home training, and in-person visits with patients on dialysis.The codes 90935, 90937, and 90955 are used to describe physician services.It makes no sense to bill for services with codes that include one or more physician evaluations when physicians are not present when a patient dialyzes daily.

The reason for the confusion about which codes to use is within the manual.It is hard to comprehend that all of the outpatient treatments provided to ESRD patients every day are lumped under a code defined as "unlisted."The failure to create codes has resulted in millions of dollars in lost reimbursement from commercial and government payers.There is a huge problem for the outpatient dialysis industry because of the internal policies of most commercial payers.When a payer refuses to reimburse for the only code that exists, how can services be billed correctly?Most payers refuse to reimburse for 90999, so they require the use of 90935, 90937, or 90955 for outpatient and outpatientPD services, respectively.There is a question of whether a code should be used for a single physician evaluation or for repeated evaluations.Bad things happen when providers are forced to choose procedure codes that do not accurately describe the services they provide.

One example of this is when a doctor is denied reimbursement for a hospital visit because a facility has already paid for that service.When an outpatient facility is denied payment because a physician already billed for that same service, the reason given by the commercial payer is that both providers are billing with the same code.It can take weeks or months to resolve the issue with payers and in some cases, the commercial payer refuses to pay despite efforts made by the provider.

The only acceptable procedure code for billing outpatient dialysis for patients with ESRD is 90999.When Medicare calculates the allowed amount, it assigns a 20% co-insurance to the patient.Medicaid in several states do not determine how much it will reimburse based on the amount assigned by Medicare, even though most patients with ESRD have a policy secondary to Medicare.If they had been the primary payers, these payers calculate how much they would have paid for the services.They subtract the amount Medicare paid from how much they would have reimbursed.This can result in a significant loss of reimbursement for providers.

For example, if Medicare allows $3,000 for a patient's monthly outpatient dialysis services, they would pay 80% or $2,400 and assign the patient co-insurance of $600.The amount the secondary payers calculate as their responsibility is usually less than the amount Medicare pays.This results in a large co-insurance amount being billed to the patient each month, which is usually beyond their ability to pay.The patient can't be billed if the secondary payer is Medicaid.

These reimbursement issues happen every month in the United States.The problems could be solved by the creation of specific codes.

There is a misinterpretation of Section 50 of Chapter 11 of the Medicare Benefit Policy Manual.If there is a medical justification for additional treatments, the maximum number of treatments that anESRD facility can pay for is 13.

The rest of the information in Section 50.A can be used to overcome this issue.In paragraph 4 it spells out how to calculate hemo-equivalents, and in paragraph 3 it explains howPD treatments are to be paid.There is a table showing how the treatments are calculated.

It's a problem to be properly reimbursed for home dialysis training.I am amazed at the number of contracts that don't include home training or reimburse for training the same rate as a regular treatment.Part of the problem is the use of CPT codes.Home training for Medicare is billed with 90999, but sometimes it is necessary to use 90989 or 90993.The code 90989 is used by physicians to bill for services related to a completed course of home training.The code 90993 is used by physicians to bill for a single training session.Reimbursement rates can vary wildly because several commercial payers do not understand the codes.

Providers should address the issues in this article now.If 90945 or 90947 are required, review commercial contracts.Make sure that home training is included in your contracts and that the reimbursement is higher than it is for standard treatments.Review Medicaid and military payers to see which codes are required.

For providers in states where Medicaid does not accept the 20% co-insurance amount assigned by Medicare, review the Medicaid remittance advice for claims paid secondary to Medicare to determine how much is being allowed for home training.Medicare Advantage Plans and traditional HMO and PPO policies should be reviewed by Nephrologists to make sure they are receiving proper reimbursement for their services.