Printer Friendly Version

Contractor Information

Contractor Name: Wisconsin Physicians Service Insurance Corporation - Full list of policies of this Medicare Contractor Contractor Number: 05401 Contractor Type: MAC A

LCD Information

LCD ID Number: L37537 Status: A-Approved LCD Title: Frequency of Hemodialysis Geographic Jurisdiction: Nebraska Other Jurisdictions Original Determination Effective Date: 03/01/2019 Original Determination Ending Date: Revision Effective Date: 03/28/2024 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: IOM Citations: CMS IOM Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual Chapter 1, §10 General Program Benefits. Chapter 2, §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 Determination(NCD) Manual, Chapter 1 Part 2, §110.10 Intravenous Iron Therapy; § 110.15: Ultrafiltration, Hemoperfusion and Hemofiltration. Part 4, §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 §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, §20 Medicare Secondary Payer Provisions for End-Stage Renal Disease (ESRD) Beneficiaries. CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, §13.5.4: Reasonable and Necessary Provisions in an LCDs. 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) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Title XVIII of the Social Security Act section 1833 (e). This section prohibits Medicare payment for any claim which 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. Sorry, you need to login or register to view additional sections of this Medicare policy. *