5160-4-14. Dialysis services provided by medical practitioners

(A) Routine maintenance dialysis.

(1) All practitioner professional services associated with the medical management of end-stage renal disease (ESRD) patients receiving maintenance dialysis are paid by the Ohio department of medicaid on a monthly capitation payment basis.

(2) Claims may be submitted for the following services in addition to the monthly capitation payment:

(a) The declotting of shunts; and

(b) Covered professional services that are unrelated to the patient's dialysis or renal condition.

(3) To receive the monthly capitation payment, the practitioner must submit a claim to the department on the last day of the month using the appropriate current procedural terminology (CPT) code.

(a) Several practitioners may form a team to provide the monthly continuity of services to a single patient or to a group of ESRD patients, or a practitioner in independent practice may make arrangements with an associate to provide the services to his/her ESRD patients when he/she is temporarily unavailable. Such arrangements are referred to as joint provisions . Under a joint provision, each practitioner may cover for another, and claims for the monthly capitation payment may be submitted by and paid to the primary practitioner. The primary practitioner must make arrangements to compensate the other practitioners involved in the dialysis care of the patient(s).

(b) When the dialysis care of a patient is provided by more than one practitioner during a calendar month and there is not a joint provision between the practitioners, the practitioners who provided the split services during the month must submit claims to the department separately using the appropriate daily dialysis care CPT code for each day the practitioner was responsible for the patient's care.

(c) For a recipient during a calendar month, the following payments should never be made:

(i) More than one monthly capitation payment ;

(ii) More than thirty-one days of daily dialysis care ; or

(iii) Payment for the monthly capitation payment and daily dialysis care. .

(4) If a dialysis patient is admitted to a hospital for no reason other than to receive maintenance dialysis (e.g., there was no space available in the dialysis unit or the patient was scheduled for extended intermittent peritoneal dialysis), payment for the professional services associated with the dialysis is still considered routine maintenance dialysis and may be paid only on a monthly capitation payment basis.

(B) Inpatient dialysis services.

(1) Except as provided for in paragraph (A)(4) of this rule, practitioners may be paid on a fee-for-service (procedure code) basis for professional services provided to hospital inpatients. To be eligible for payment on a fee-for-service basis, the practitioner must be present with the patient at some time during the dialysis, the patient's medical records must document that the practitioner was present, and the dialysis must be performed for one of the following reasons:

(a) For acute renal failure or renal trauma;

(b) As an initial course of dialysis (the "initial course of dialysis" means the first dialysis treatment and all subsequent dialysis treatments performed prior to the patient's stabilization on dialysis); or

(c) For an ESRD patient who was admitted to the hospital for a condition or illness unrelated to the patient's renal condition and the practitioner has elected to submit a claim for the inpatient dialysis services on a fee-for-service basis. If the practitioner has elected to submit a claim for the inpatient dialysis services on a fee-for-service basis and the practitioner usually is paid the monthly capitation payment, the practitioner may not

submit a claim for the monthly capitation payment that month and must instead submit a claim using the appropriate daily dialysis care CPT code only for the days when the patient was not a hospital inpatient.

(2) For payment for inpatient dialysis services on a fee-for-service basis, the provider must submit a claim with the appropriate inpatient dialysis care CPT code. .

(3) All evaluation and management services related to the patient's end stage renal disease that are rendered on a day when dialysis is performed and all other patient care services that are rendered during the dialysis procedure are included in the payment for hemodialysis and other dialysis care procedure codes.

Effective: 10/1/2016
Five Year Review (FYR) Dates: 06/23/2016 and 10/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 09/01/1989, 05/25/1991, 12/01/1992, 102/31/1992 (Emer), 04/01/1993, 12/29/1995 (Emer), 03/21/1996, 12/31/2008 (Emer), 03/31/2009