Creation/Revision Date: November 16, 2009
MLN Matters® Number: SE0921 Related Change Request (CR) #: N/A
Related CR Release Date: N/A Effective Date: N/A
Related CR Transmittal #: N/A Implementation Date: N/A
Visit Requirements Clarification for CR 5931 “Manualization of Payment for Outpatient ESRD Related Services”
Provider Types Affected
Physicians and other practitioners who bill Medicare contractors (carriers or Medicare Administrative Contractors (A/B MAC)) for providing outpatient end stage renal disease (ESRD) services to Medicare Beneficiaries.
Provider Action Needed
STOP – Impact to You
This special edition article clarifies visit requirements under the end stage renal disease (ESRD) monthly capitation payment (MCP).
CAUTION – What You Need to Know
Once a patient is on dialysis, the MCP physician (or practitioner) must furnish at least one face-to-face visit per month to the beneficiary in his/her office, outpatient hospital, or other outpatient setting, which can include the patient’s home as well as in the dialysis facility. The MCP physician (or practitioner) is not required to furnish the visit while the patient is dialyzing.
GO – What You Need to Do
See the Background and Additional Information Sections of this article for further details regarding these changes.
The Centers for Medicare & Medicaid Services (CMS) is providing this special edition article to clarify visit requirements under the end stage renal disease (ESRD) monthly capitation payment (MCP) as described in CR 5931 “Manualization of Payment for Outpatient End Stage Renal Related (ESRD) Services.” An MLN Matters® article related to CR 5931 is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5931.pdf on the CMS website.
Once the ESRD beneficiary is on dialysis, the MCP physician (or practitioner) must furnish at least one face-to-face visit per month to the beneficiary. MCP visits may be furnished in a physician’s office, outpatient hospital or other outpatient setting including the patient’s home as well as in the dialysis facility. The MCP physician (or practitioner) is not required to furnish the visit while the patient is dialyzing.
For example, a comprehensive monthly visit could be furnished in a physician’s office; at a different time than the beneficiary’s dialysis session.
If you have any questions, please contact your carrier or A/B MAC at their toll-free number, which may be found athttp://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website.
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2008 American Medical Association.