LCD ID Number: L35014 Status: A-Approved
LCD Title: Frequency of Hemodialysis
Geographic Jurisdiction: Oklahoma Other Jurisdictions
Original Determination Effective Date:
Original Determination Ending Date:
Revision Effective Date:
Revision End Date:
CMS National Coverage Policy:
This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for additional hemodialysis sessions. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for additional hemodialysis sessions and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:
- CMS IOM Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual
- Chapter 1, Section 10 General Program Benefits
- Chapter 2, Section 10 Hospital Insurance Entitlement
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 11, End Stage Renal Disease (ESRD)
- CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1
- Part 2, Section 110.10 Intravenous Iron Therapy; Section 110.15 Ultrafiltration, Hemoperfusion and Hemofiltration
- Part 4, Section 260.6 Dental Examination Prior to Kidney Transplantation
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 8 Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, all sections including Section 140 Monthly Capitation Payment Method for Physicians’ Services Furnished to Patients on Maintenance Dialysis
- CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 2, Section 20: Medicare Secondary Payer Provisions for End-Stage Renal Disease (ESRD) Beneficiaries
- CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD
Change Request References:
- Change Request 5039, Transmittal 1084, October 27, 2006: Line Item Billing Requirement for End Stage Renal Disease (ESRD) Claims
- Change Request 9989, Transmittal 1849, May 12, 2017: Implementation of Modifier CG for Type of Bill 72x
- Change Request 10901, Local Coverage Determinations (LCDs)
Social Security Act (Title XVIII) Standard References:
- Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
- Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
Federal Register References:
- 42 CFR, Chapter IV, Subchapter G, Part 494, Subpart C,
- Section 494.80 Condition: Patient assessment
- Section 494.90 Condition: Patient plan of care
- CMS Final Rule CMS-1651-F published November 4, 2016
Note: Italicized font represents CMS manual titles, journal titles and/or CMS national NCD language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national NCD language/wording.
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