Effective for dates of service on or after December 1, 2007, renal dialysis services
benefit criteria will change for the Texas Medicaid Program.
Renal dialysis is an artificial process by which waste products and excess fluid are
removed from the body by diffusion from one fluid compartment to another across a
semipermeable membrane. Active or mechanical dialysis cycles blood through a
machine (dialyzer) or cycles dialyzing fluid into and out of the clients abdominal cavity
(peritoneum) through a semipermeable membrane to remove impurities and toxins and
to maintain fluid, electrolyte and an acid-base balance. Passive dialysis uses the client’s
peritoneal membrane as the filter.
Maintenance renal dialysis, training, ultrafiltration, and related physician services are
benefits of the Texas Medicaid Program for acute renal failure and end-stage renal
disease (ESRD).
Acute renal failure may require dialysis until the client’s kidney function improves and
starts filtering the client’s blood independently. ESRD is defined as irreversible, chronic
renal failure requiring regular dialysis or a kidney transplant to sustain life. The following
diagnosis codes should be used for acute renal failure and ESRD:
Diagnosis Codes
5845
5846
5855
5856
5847
5848
5849
According to the guidelines for outpatient maintenance dialysis approved through the
Centers for Medicare & Medicaid Services (CMS), dialysis treatments are benefits for
clients in the inpatient hospital setting, the outpatient hospital setting, or a renal dialysis
facility. Dialysis treatments may also be a benefit in the client’s home.
Outpatient dialysis is furnished on an outpatient basis at a renal dialysis center, facility,
or home. Outpatient dialysis includes:

Staff-assisted dialysis performed by the staff of the center or facility.

Self-dialysis performed by a client with little or no professional assistance. The client
must have completed an appropriate course of training.

Dialysis performed by an appropriately trained client and the client’s caregiver at
home.

Dialysis furnished in an approved renal dialysis facility on an outpatient basis.
Whole blood for transfusions may be considered for reimbursement separately to
dialysis facilities when medically indicated for a Medicaid-eligible client. Administration of
the blood transfusion is not considered for reimbursement separately to dialysis facilities,
but may be considered for reimbursement to the medical professional administering the
blood product.
The following services are not benefits of the Texas Medicaid Program:

Installation and repair of home hemodialysis machines.

Home modifications for use of medical equipment.
All physician, renal dialysis center, and medical supplier supporting documentation is
subject to retrospective review.
The Texas Medicaid Program reimburses providers for dialysis services through either
Method I or Method II as defined by the CMS. Method I and Method II reimbursement
applies to the hemodialysis, intermittent peritoneal dialysis (IPD), continuous ambulatory
peritoneal dialysis (CAPD), and continuous cycling peritoneal dialysis (CCPD) laboratory
and radiology services and the physician supervision of dialysis clients. Details are
provided in the designated sections below.
Types of Dialysis Procedures
There are two types of renal dialysis procedures in common clinical usage: hemodialysis
and peritoneal dialysis. Both hemodialysis and peritoneal dialysis are acceptable modes
of treatment and are benefits of the Texas Medicaid Program.
Hemodialysis
During the hemodialysis process, blood passes through an artificial kidney machine and
the waste products diffuse across a synthetic membrane into a bath solution known as
dialysate after which the cleansed blood is returned to the client’s body. Hemodialysis is
accomplished usually in three- to four-hour sessions, three times a week.
Occasionally, medical complications occur where a client retains more fluid than is
healthy following a regular dialysis treatment. A separate ultrafiltration treatment to
remove the excess fluid may be a benefit of the Texas Medicaid Program. Ultrafiltration
is a process of removing excess fluid from the blood through a dialysis membrane by
exerting pressure. This procedure is part of a hemodialysis treatment and is included in
the composite rate for the hemodialysis treatment. Ultrafiltration is not a substitute for
dialysis.
Peritoneal Dialysis
During the peritoneal dialysis process, waste products pass from the client’s body
through the peritoneal membrane into the peritoneal (abdominal) cavity where the
dialysate is introduced and removed periodically.
IPD is the process where waste products pass from the client’s body through the
peritoneal membrane into the peritoneal cavity where the dialysate is introduced and
removed periodically by machine. IPD generally is required for approximately 30 hours a
week, either as three 10-hour sessions or less frequent, but longer, sessions.
CAPD is a process where the client’s peritoneal membrane is used as a dialyzer. During
the day, the client connects a bag of dialysate to a surgically implanted indwelling
catheter that allows the dialysate to pour into the beneficiary’s peritoneal cavity. Several
hours later, the fluid is drained out into the same bag. CAPD is administered three to five
times a day.
CCPD is a treatment modality that combines the advantages of the long dwell,
continuous steady state dialysis of CAPD, with the advantages of automation inherent in
IPD. The major difference between CCPD and CAPD is that the solution exchanges,
which are performed manually during the day by the client on CAPD, are moved to
nighttime with CCPD and are performed automatically with a peritoneal dialysis cycler.
At night, the client connects a surgically implanted catheter to the cycler system, which
has four suspended containers of dialysate. The cycler automatically empties the client’s
peritoneal cavity of any dialysate. The cycler then cycles the nocturnal exchanges
automatically while the client sleeps. Generally there are three nocturnal exchanges
occurring at intervals of 2 ½ to 3 hours, with the fourth exchange being instilled in the
morning upon awakening. Upon waking, the client disconnects from the cycler leaving
the last dialysate inside the peritoneum.
Prior Authorization
Prior authorization is not required for renal dialysis services. Prior authorization must be
obtained for transplant-related services provided to clients who are not eligible for
Medicare and are eligible only for Medicaid.
Medicare- and Medicaid-Eligible Clients
If a Medicaid client is also eligible for Medicare benefits, the client’s Medicaid benefits for
the renal dialysis begin with the original onset date of the dialysis treatments and may
continue for a period of three months as Medicare eligibility usually begins after a threemonth waiting period has been served. During this period, Medicare eligibility is
reviewed through the Health and Human Services Commission (HHSC). If HHSC
determines that the client is Medicare-eligible, the Medicaid renal dialysis benefits begin
with the original onset date and continue until the Medicare benefits begin. Medicare
eligibility may begin before the waiting period has expired if the individual receives a
transplant or participates in a self-dialysis training program during the waiting period.
If HHSC determines that the client is not eligible for Medicare, the client’s Texas
Medicaid Program renal dialysis benefits begin with the original onset date and continue
as long as the dialysis treatments are medically necessary and as long as the client’s
Medicaid eligibility continues. The date of onset is the date of the first dialysis treatment
and does not change even if the client sees another provider.
Renal Dialysis Facilities—Method I Composite Rate
Renal dialysis facilities are reimbursed according to composite rates, which are based
on CMS-specified calculations and the Texas Medicaid Reimbursement Methodology
(TMRM).
The facility bills an amount that represents the charge for the facility’s service to the
dialysis client. The facility’s charge must not include the charge for the physician’s
routine supervision.
The composite rate includes all necessary equipment, supplies, and services for the
client receiving dialysis whether in the home or in a facility. Examples include, but are
not limited to, the following:

Cardiac monitoring (procedure codes 5-93040 and T-93041).

Catheter changes (procedure codes 2-36000, 2-49420, and 2-49421).

Crash cart usage for cardiac arrest.

Declotting of shunt performed by facility staff (hemodialysis) (procedure code 236550).

Dialysate (procedure codes 9-A4720, 9-A4722, 9-A4723, 9-A4724, 9-A4725, 9A4726, and 9-A4765).

Oxygen (procedure codes L-E0424, L-E0431, L-E0434, L-E0439, L-E0441, L-E0442,
L-E0443, and L-E0444).

Routine laboratory services for dialysis.
Note: When one of these laboratory services is required more frequently, renal dialysis
facility providers should bill the appropriate procedure code with modifier 91 for separate
reimbursement.

Staff time to administer blood, separately billable drugs, and blood collection for
laboratory (procedure codes 2-36430 and 2-36540).

Suture removal or dressing changes.

Certain drugs such as those to elevate or decrease blood pressure, antiarrythmics,
blood thinners or expanders, antihistamines, or antibiotics to treat infections or
peritonitis are included in the composite. Examples include, but are not limited to:
Drug
Procedure Code
Hydralazine
1-J0360
Diphenenhydramine 1-J1200
Heparin
1-J1642, 1-J1644
Dopamine
1-J1265
Glucose
N/A
Propranolol
1-J1800
Insulin
N/A
Digoxin
1-J1160
Norepinephrine
bitartrate
N/A
Mannitol
1-J2150
Procaine
N/A
Protamine
1-J2720
Saline
9-A4216, 9-A4217
Hydrocortisone
sodium succinate
1-J1720
Verapamil
N/A
Training for Hemodialysis, IPD, CCPD and CAPD
Most self-dialysis training for hemodialysis, IPD, CCPD, and CAPD is provided in an
outpatient setting. Providers are reimbursed at the same rate as the facility’s outpatient
training rate for dialysis training provided in an inpatient setting.
Reimbursement for hemodialysis, IPD, CCPD, and CAPD training services and supplies
provided by the dialysis facility include personnel services, parenteral items routinely
used in dialysis, training manuals and materials, and routine dialysis laboratory tests.
No frequency limitation is applied to routine laboratory tests during the training period
because these tests are commonly given during each day of training. Nonroutine
laboratory tests performed during the training period may be considered for
reimbursement when documentation of medical necessity is submitted with the claim.
IPD or hemodialysis may be necessary in order to supplement the patient’s dialysis
during CAPD training because the client has not mastered the CAPD technique.
Training is limited to once per day. The composite rate is denied as part of dialysis
training when billed with the same date of service.
Maintenance Hemodialysis
The facility composite rate applies when a chronic renal disease client receives dialysis
in an approved renal dialysis facility. Reimbursement is based on the facility’s pertreatment composite rate, as calculated by Medicare. Services included in the facility’s
charge are routine laboratory tests, personnel services, equipment, supplies, and other
services associated with the treatment.
When a client is admitted for hospitalization for no reason other than to receive
maintenance renal dialysis, the dialysis services are considered outpatient services and
are benefits if the hospital has been designated as a CMS-certified renal dialysis center.
Maintenance IPD
Maintenance IPD is usually performed in sessions of 10 to 12 hours in duration, 3 times
per week. It may also be performed in fewer sessions that are longer in duration. If more
than 3 sessions occur in one week, the provider must supply documentation of medical
necessity with the claim.
Maintenance CAPD and CCPD
Support services for maintenance furnished to clients receiving CAPD or CCPD in the
home may be considered for reimbursement to dialysis facilities. Home dialysis support
services must be furnished by the facility in either the home or the facility. CAPD and
CCPD support services are limited to once per day.
Method II Working Direct
Support Services
With Method II, the client selects and works with a single supplier to obtain supplies and
equipment to dialyze at home. The selected supplier cannot be a dialysis facility,
although the supplier must maintain a written agreement with a support dialysis facility to
provide backup and support services. Method II support services are reimbursed under
procedure codes B-845 and B-855.
Support services are considered for reimbursement monthly under Method II, are limited
to clients 20 years of age and younger, and include but are not limited to, the following:

Periodic monitoring of a client’s adaptation to home dialysis and performance of
dialysis, including provisions for visits to the home or the facility.

Visits by trained personnel for the client with a qualified social worker and a qualified
dietitian, made in accordance with a plan prepared and periodically reviewed by a
professional team which includes the physician.

Individual unscheduled visits to a facility made on an as-needed basis (for example:
assistance with difficult access situations).

The same ESRD related laboratory tests covered under the composite rate.

Providing, installing, repairing, testing, and maintaining home dialysis equipment,
including appropriate water testing and treatment.

Ordering of supplies on an ongoing basis.

A record keeping system that assures continuity of care.

Support services specifically applicable to CAPD also include, but are not limited to,
the following:
o
Changing connecting tube/administration set.
o
Monitoring the client’s performance of CAPD, assuring that it is done correctly, and
reviewing proper techniques with the client or informing the client of modifications
to apparatus or technique.
o
Documenting whether the client has or has had peritonitis that requires physician
intervention or hospitalization (unless there is evidence of peritonitis, a culture for
peritonitis is not necessary).
o
Inspecting the catheter site.
Routine laboratory services are included in the support services and are not reimbursed
separately.
Equipment and supplies are:

Reimbursed under Method II to only one provider per month who must agree to bill
once per month for only one month’s quantity per claim.

Limited to clients 20 years of age and younger.

Reimbursed separately up to the total monthly allowable amount as determined by
HHSC.
The following equipment and supply procedure codes are benefits of the Texas Medicaid
Program:
Procedure Codes
2-36000
2-36430
2-36540
2-36550
2-49420
2-49421
5-93040
T-93041
9-A4216
9-A4217
9-A4651
9-A4652
9-A4657
9-A4660
9-A4663
9-A4670
9-A4680
9-A4690
9-A4706
9-A4707
9-A4708
9-A4709
9-A4714
9-A4719
9-A4720
9-A4721
9-A4722
9-A4723
9-A4724
9-A4725
9-A4726
9-A4730
9-A4736
9-A4737
9-A4740
9-A4750
9-A4755
9-A4760
9-A4765
9-A4766
9-A4772
9-A4773
9-A4774
9-A4802
9-A4860
9-A4911
9-A4913
9-A4918
9-A4927
9-A4928
9-A4929
9-A4930
9-A4931
9-A4932
L-E0424
L-E0431
L-E0434
L-E0439
L-E0441
L-E0442
L-E0443
L-E0444
J/L-E1510
J/L-E1520
J/L-E1530
J/L-E1540
J/L-E1550
J/L-E1560
J/L-E1570
J/L-E1575
J/L-E1580
J/L-E1590
Procedure Codes
J/L-E1592
J/L-E1594
L-E1600
J/L-E1620
J/L-E1630
J/L-E1632
J/L-E1635
L-E1636
J-E1637
J/L-E1639
J/L-E1699
1-J0360
1-J1160
1-J1200
1-J1265
1-J1642
1-J1644
1-J1720
1-J1800
1-J2150
1-J2720
Note: Procedure codes 9-A4651 through 9-A4932 and J/L-E1510 through J/L-E1699
listed above are benefits of the Texas Medicaid Program for DME suppliers billing under
Method II Reimbursement - Dealing Direct.
Clients can have a one month reserve of supplies available for use. Renal dialysis
services beyond these limitations may be considered for reimbursement for clients from
birth through 20 years of age through THSteps-CCP with prior authorization.
A client with Medicaid coverage may receive CAPD or CCPD support services furnished
by the facility on a monthly basis. Charges for support services in excess of this
frequency must include documentation of medical necessity.
The following services are benefits of the Texas Medicaid Program for renal dialysis
centers billing under Reimbursement Method I Composite Rate or Method II Working
Direct. Method II is limited to clients 20 years of age and younger:
Service
Revenue Codes
Hemodialysis
B-821, B-829
IPD
B-831, B-839
CAPD
B-841, B-845, B-849
CCPD
B-851, B-855, B-859
Ultrafiltration
B-881
Laboratory and Radiology Services
Hemodialysis, IPD and CCPD: In-Facility Dialysis—Routine Laboratory
Services
Laboratory testing may be obtained and processed in the renal dialysis facility or by an
outside laboratory. Charges for routine laboratory tests performed according to the
established frequencies in the following tables are included in the facility’s composite
rate billed to the Texas Medicaid Program regardless of where tests are processed. If
the routine laboratory testing is processed by an outside laboratory, the outside
laboratory will bill the renal dialysis facility; the renal dialysis facility will then bill the
Texas Medicaid Program unless the test results are inconclusive.
Frequency
Procedure Codes
Per dialysis
5-85014
5-85345
5-85347
Per week
5-82565
5-84520
5-85610
Per month
5-82040
5-82310
5-82374
5-82435
5-83615
5-84075
5-84100
5-84132
5-85018
Frequency
Procedure Codes
5-84155
5-84450
5-85025
5-85027
These routine tests are frequently performed as an automated battery of tests such as
the SMAC-12 (chemistry panels). These tests are considered routine and are included in
the charge for dialysis unless there is an additional diagnosis to document medical
necessity for performing the tests in excess of the recommended frequencies.
If additional in-facility laboratory testing is medically necessary beyond the routine
frequencies identified above, providers must indicate the test on the claim form, must bill
the appropriate procedure code with modifier 91 to indicate the billed laboratory
procedure is medically necessary, and must submit documentation supporting this
medical necessity. The supporting documentation must also be maintained by the
client’s physician and in the client’s medical record at the renal dialysis center.
Modifier 91 is used to indicate that a test was performed more than once on the same
day for the same client only when it is necessary to obtain multiple results in the course
of the treatment. This modifier may not be used to indicate any of the following
situations:

When tests are re-run to confirm initial results.

Testing problems with specimens or equipment.

A normal one-time, reportable result is all that is required.

When there are standard Healthcare Common Procedure Coding System (HCPCS)
codes available that describe the series of results (for example: glucose tolerance
tests, evocative/suppression testing, etc.).
Modifier 91 may only be used for laboratory tests paid under the clinical diagnostic
laboratory fee schedule.
Hemodialysis, IPD, and CCPD—In-Facility Dialysis—Nonroutine Laboratory
Services
The following procedure codes and frequencies are considered necessary, nonroutine
tests. They must be billed separately from the dialysis charge when performed in the
chronic renal dialysis (CRD) facility or by an outside laboratory that bills the facility for
laboratory services. All nonroutine laboratory and radiology tests beyond the
recommended frequencies require medical justification.
Frequency
Procedure Codes
Once a month
5-87340
Every three months
T-93005
Every six months
4-71010, 4-71020, 5-95900
Annually
4-78300, 4-78305, 4-78306
If additional in-facility laboratory testing is medically necessary beyond the nonroutine
frequencies identified above, providers must bill with modifier 91 to indicate the billed
laboratory procedure is medically necessary, and the billing provider must maintain
documentation supporting this medical necessity in the client’s medical record.
A handling fee (procedure code 1-99001) for nonroutine laboratory services may be
billed to the Texas Medicaid Program only if the specimen is obtained by venipuncture or
catheterization and sent to an outside lab. The claim form must document that the
handling fee is for nonroutine laboratory services.
CAPD
The following laboratory tests are routine for home maintenance CAPD clients when
performed according to the indicated frequency. These laboratory tests may be
reimbursed separately when the client is dialyzing in the home and is not undergoing
IPD or hemodialysis in the facility. The provider must indicate the client’s diagnosis and
the type of dialysis on the claim form.
Frequency
Procedure Codes
Every month
5-82040
5-82310
5-82374
5-82565
5-83615
5-83735
5-84075
5-84100
5-84132
5-84155
5-84295
5-84450
5-84520
5-85014
5-85018
Every three
months
5-85004
5-85007
5-85008
5-85014
5-85027
5-85041
Every six
months
4-71010
4-71020
4-78300
4-78305
4-78306
5-80069
5-81050
5-95900
T-93005
Tests in excess of these frequencies or tests not listed in the table above require
documentation of medical necessity to be considered for reimbursement. This
documentation must be maintained by the client’s physician and the renal dialysis center
in the client’s medical record.
Physician Supervision of Dialysis Clients
Physician reimbursement for supervision of clients on dialysis is based on a monthly
capitation payment (MCP) calculated by Medicare. The MCP is a comprehensive
payment that covers all physician services associated with the continuing medical
management of a maintenance dialysis client for treatments received in the facility. An
original onset date of dialysis treatment must be included on claims for all renal dialysis
procedures in all places of service except inpatient hospital.
Use the following procedure codes when billing for physician supervision for outpatient
dialysis regardless of place of service:
Procedure Codes
1-90918
1-90919
1-90920
1-90923
1-90924
1-90925
1-90921
1-90922
When a full month of supervision has been provided, procedure codes 1-90918, 190919, 1-90920, and 1-90921 may be used. The date of service must reflect the first day
of the month that supervision was provided. The quantity is one.
When supervision is for less than a full month (for example, the client is hospitalized or is
out of the area), procedure code 1-90922 may be used. This procedure code represents
a per day charge used to bill the supervision when a full month is not provided. The
dates of service must indicate each day that supervision was provided and the quantity
must be the same as the number of days listed for the month.
The procedure codes in the above table may be used to submit claims for office visits for
the routine evaluation of client progress, or for treatment of renal disease complications
including evaluation of diagnostic tests and procedures.
The procedure codes in the above table may be used to submit claims for all physician
services rendered by the attending physician in the course of office visits where the
primary purpose is either the routine monitoring or the follow-up of complications of
dialysis. Follow up of complications includes services involved in prescribing therapy for
illnesses unrelated to renal disease if the treatment occurs without increasing the
number of physician-client contacts beyond those occurring at dialysis, regular
monitoring sessions, or visits for treatment of renal complications.
The following services may be provided in conjunction with dialysis but are considered
nonroutine and may be billed separately:

Declotting of shunts when performed by the physician.

Physician services to inpatients. The physician should bill procedure code 1-90922
for each date of outpatient supervision and bill the appropriate hospital E/M
procedure code for individual services provided on the hospitalized days.

Dialysis at an outpatient facility other than the usual dialysis setting for a client of a
physician who bills the MCP. The physician must bill procedure code 1-90922 for
each date the supervision is provided. The physician may not bill for days that the
client dialyzed elsewhere.

Physician services beyond those that are related to the treatment of the client’s renal
condition that cause the number of physician-client contacts to increase. Physicians
may bill on a fee-for-service basis if they supply documentation on the claim that the
illness is not related to the renal condition and that additional visits are required.
Procedure codes 1-90935, 1-90937, 1-90945, and 1-90947 are for complete care of the
client and may be used for inpatient dialysis services when the physician is present
during dialysis treatment. The nephrologist must be physically present and involved
during the course of the dialysis. These procedure codes are not payable for a cursory
visit by the nephrologist; hospital visit procedure codes must be used for a cursory visit.
Hospital visits cannot be billed with the same dates of service as procedure codes
1-90935, 1-90937, 1-90945, and 1-90947. However, if the physician only sees the client
when they are not dialyzing, the physician should bill the appropriate hospital visit
procedure code. The inpatient dialysis procedure code should not be submitted for
payment.
The following services are considered part of the physician’s charge under the MCP for
supervision of a client on self dialysis. These services may be billed by the physician on
a fee-for-service basis:

Declotting of shunts.

Inpatient services provided to hospitalized clients for whom the physician has agreed
to bill monthly. These services may be considered for reimbursement in one of the
following three ways:
o
The physician may elect to continue monthly billing, in which case the physician
may not bill for individual services provided to the hospitalized clients.
o
The physician may reduce the monthly bill by 1/30th for each day of hospitalization
and charge fees for individual services provided on the hospitalized days.
o
The physician may bill for inpatient dialysis services using the inpatient dialysis
procedure codes. The physician must be present and involved with the clients
during the course of the dialysis.
Clients may receive dialysis at an outpatient facility other than the usual dialysis setting,
even if their physician bills for monthly dialysis coordination. The physician must reduce
the monthly billed amount by 1/30th for each day the client is dialyzed elsewhere.
Physician services beyond those related to the treatment of the client’s renal condition
may be considered for reimbursement on a fee-for-service basis. The physician should
provide documentation stating the illness is not related to the renal condition and added
visits are required.
Payment is made for physician training services in addition to the monthly capitation
payment for physician supervision rendered to maintenance facility clients.
Additional changes include the following:
Effective for dates of service on or after December 1, 2007, providers will no longer be
reimbursed for the following diagnosis codes:
Noncovered Diagnosis Codes
40300
40301
40310
40311
40403
40412
4822
5820
5821
5822
5824
58281
58289
5829
5834
5851
5852
5853
5854
5859
586
99656
99668
99673
V451
V560
V5631
V5632
V568
In addition, the following renal dialysis procedure codes 1-90918, 1-90919, 1-90920, 190921, 1-90922, 1-90923, 1-90924, 1-90925, 1-90935, 1-90937, 1-90945, or 1-90947
may no longer be reimbursed to a registered nurse or certified nurse midwife.