END STAGE RENAL DISEASEPROVIDER MANUALapter Seventeenof the MedicaidSe - PDF document

END STAGE RENAL DISEASEPROVIDER MANUALapter Seventeenof the MedicaidServices ManualIssued February 1, 2012 Claims/authorizations for dates of service on or after October 1, 2015 must use the applicable ICD10 diagnosis code that reflects the policy intent. References in this manual to ICD9 diagnosis codes only apply to claims/authorizations with dates of service prior to October 1, 2015.State ofLouisiana Bureau of Health Services Financing LOUISIANA MEDICAID PROGRAMISSUED:01/23/21REPLACED:02/01/12CHAPTER END STAGE RENAL DISEASE APPENDIX ACONTACT INFORMATIONPAGE(S) Contact InformationPage of Appendix A TYPE OF ASSISTANCE CONTACT INFORMATION Who to contact for assistance with billing questions/problemsGainwell TechnologiesProvider Relations UnitP. O. Box 91024 How to access other Louisiana Medicaid provider manuals under “Provi

der Manuals” link LOUISIANA MEDICAID PROGRAMISSUED:09/20/21REPLACED:07/17/12CHAPTER END STAGE RENAL DISEASE SECTION Provider RequirementsPage of Section PROVIDER REQUIREMENTSProvider Certification LOUISIANA MEDICAID PROGRAMISSUED:09/20/21REPLACED:07/17/12CHAPTER END STAGE RENAL DISEASE SECTION: TABLE OF CONTENTSPAGE(S) Page of Table of Contents SUBJECTSECTION OVERVIEWSECTION LOUISIANA MEDICAID PROGRAMISSUED:/22REPLACED:09/20/21CHAPTER END STAGE RENAL DISEASE SECTION 17.3: REIMBURSEMENTPAGE(S) ReimbursementPage of Section poetin AlfaEpoetin alfa (EPOis reimbursed per 1,000 units (rounded to the nearest 100 units) administered. The following formula is used in calculating EPO reimbursement:(Total number of EPO units/100) X $1.00 = Reimbursement**All claimsMedicare and Medicare, are subject to the following rate reduc

tions:Effective February 26, 2009, 3.5%Effective January 22, 2010, 5%Effective August 1, 2010, 4.6%Effective January 1, 2011, 2%; andEffective July 1, 2012, 3.7% LOUISIANA MEDICAID PROGRAMISSUED:/22REPLACED:09/20/21CHAPTER END STAGE RENAL DISEASE SECTION 17.3: REIMBURSEMENTPAGE(S) ReimbursementPage of Section REIMBURSEMENTReimbursement for the technical component of dialysisservices must be billed using the UBclaim form or its successor. LOUISIANA MEDICAID PROGRAMISSUED:REPLACED:09/20/21CHAPTER 17: END STAGE RENAL DISEASE APPENDIX B: CLAIMS FILINGPAGE(S) Claims FilingPage of Appendix B CLAIMS FILINGClaims for end stage renal disease (ESRD)ervices must be filed by electronic claims submission 837I or on the UB 04 claim form. LOUISIANA MEDICAID PROGRAMISSUED:05/26REPLACED:09/20/21CHAPTER END STAGE RENAL DISEASE SECTION 17.1:

COVERED SERVICESPAGE(S) Covered ServicesPage of Section The beneficiary’sphysician or facility must develop an appropriately designed protocol for the beneficiaryfor the safe and effective use of the drug. The protocol must include monitoring the beneficiary’sblood pressureThe beneficiarymust be capable of performing selfadministration of EPO, be able to read the drug labeling, or have a primary caregiver who can perform these tasks; andThe beneficiarymust be able to adhere to a disciplined medical program.Patient Care PlanTo ensure adequate monitoring of home EPO therapy, the patientcare plan for a beneficiary who is home dialysis patientusingEPO in the home must include the following:A review of diet and fluid modification to monitor iron stores and hyperkalemia related to dietary indiscretion or elevated blood pressureA

reevaluation of the beneficiary’sdialysis prescription, taking into account the beneficiary’sincreased appetite and red blood cell volumeA method of teaching the beneficiaryto identify the signs and symptoms ohypotension and hypertensionThe decrease or discontinuance of EPO if hypertension isuncontrolledandA method of followup on blood work and a means to keep the physician informed of the results.If a beneficiaryis not competent to use EPO in the home without supervision, and the drug has been prescribed, the dialysis facility should administer the drug.Medically Necessary InjectionsCertain injections that are covered under Louisiana Medicaid are usually billed in connection with hemodialysis treatments.Reimbursement for each of these itemsONLYcovers the cost of the drug.Reimbursement for the administration of the injection

is included in the physician supervision of dialysis procedures.Medicaid does not automatically cover new drugs when they are introduced. If a drug is added to the Medicare file, Medicaid will consider payment of the Medicaid portion of the claim. LOUISIANA MEDICAID PROGRAMISSUED:05/26REPLACED:09/20/21CHAPTER END STAGE RENAL DISEASE SECTION 17.1: COVERED SERVICESPAGE(S) Covered ServicesPage of Section Circumstances in which the bone marrow is replaced with other tissue, such as malignancy or osteitis fibrosa cysticandBeneficiary’sweight, requiredcurrent dose, a historical record of the amount that has been given, and the hematocrit response to date.Coverage can be made for facilitydialyzed beneficiaries, as well as for beneficiarieswho dialyze at home and are competent to use the drug without medical or other supervision. The

facility is required to limit the “onhand” supply to home dialysis beneficiariesup to a twomonth supply. The facility may bill up to a twomonth supply initially, and must thereafter bill a onemonth supply.Criteria for Selection of BeneficiariesQualified to SelfAdministered EPO in the HomeThe beneficiary’sdialysis facility or the physician responsible for furnishing all dialysisrelated ervices to the beneficiarycan participate in beneficiary selection, training, and monitoring.In considering EPO therapy in the home setting, it is important for the dialysis facility or the physician responsible for all dialysisrelated services to assess the degree of selfcare that is feasible; i.e., whether the beneficiarywill actually be able to administer the drug, and if not, whether the beneficiarywould have the necessary assistance fro

m aavailablecaregiver. In order to be selected for home use of EPO, the beneficiarymust meet the following criteria: Be a home dialysis patient (utilizing either CAPD or CCPD method)Have a hematocrit (or comparable hemoglobin) of less than 30percent, unless edical documentation justifies a beneficiary’sneed for EPO with a hematocrit higher than 30percentBe under the care of the physician who is responsible for the dialysisrelated services and who prescribes EPO, and be under the care of the renal dialysis facility that establishes the plan of care for the services and monitors the progress of the home EPO therapyandBe trained by the facility to inject EPO or have an appropriate caregiver who is trained to inject EPO.In addition, the following requirements must be met:Prior to the determination that the beneficiary is a candidate fo

r use of EPO in the home, the beneficiary’s hematocrit (or hemoglobin), serum iron, transferrin saturation, serum ferritin, and blood pressure must be measured LOUISIANA MEDICAID PROGRAMISSUED:05/26REPLACED:09/20/21CHAPTER END STAGE RENAL DISEASE SECTION 17.1: COVERED SERVICESPAGE(S) Covered ServicesPage of Section NonRoutine Laboratory ServicesCoveredroutine services performed by approved Medicaid laboratoriesmust be medicalnecessaryand documented by the physician.Claims forhese medically necessary services may be submittedseparately by either the contracted laboratory or by the dialysis facility. The ESRD facility and their contracted laboratory must coordinate billing to ensure duplicate payments do not occur. All claims are subject to post payment review and recoupmentof over payments.Billed charges on claims for covered n

onroutine laboratory services submitted by the dialysis provider shall not exceed the amount the dialysis provider paid to their contracted laboratory for the same procedure on the same date of service.poetin Epoetin lfa (EPO)also referred to as Epoetin or Epogen, is covered under Louisiana Medicaid when it is used to treat anemia associated with chronic renal failure.Beneficiarieswith this condition include those who require renal dialysis and are eligible for Medicare under the ESRD provisions of the law.EPO may be administered either intravenously or subcutaneously for the treatment of anemia associated with chronic renal failure.Providers should address the following in their medical documentation:Iron deficiency (st beneficiarieswill need supplemental iron therapy while being treated, even if they do not start out iron deficient)Co

ncomitant conditions such as infection, inflammation, or malignancy (These conditions should be addressed insofar as possible for EPO to have maximum effect)Unrecognized blood loss beneficiarieswith kidney disease and anemia may have chronic blood lossusually gastrointestinalas a reason for the anemias a result, the effectiveness of EPO will be limited)Concomitant hemodialysis, bone marrow dysplasia, or refractory anemia for a reason other than renal disease, such as aluminum toxicityFolic acid or vitamin B12 LOUISIANA MEDICAID PROGRAMISSUED:05/26REPLACED:09/20/21CHAPTER END STAGE RENAL DISEASE SECTION 17.1: COVERED SERVICES PAGE(S) 6 Covered ServicesPage 3 of 6 Section Routine lab serviceswiththe allowed frequency are included in the following table: HEMODIALYSIS PERITONEAL DIALYSIS Frequency Routine Lab Service Frequency Routine

Lab Service PER DIALYSIS Hematocrit MONTHLY BUN WEEKLY Prothrombin time for beneficiaries on anticoagulant therapy Creatinine Serum CreatinineSodium BUNDialysate Protein MONTHLY Albumin Hgb Serum CalciumCarbon Dioxide Serum Potassium LDH Serum Chloride Phosphate Serum BicarbonateSGOT Serum Phosphorus Magnesium Alkaline Phosphates Total ProteinCalcium Serum AlbuminTotal Protein Alkaline Phosphatase Potassium SGOTHCT LDH LOUISIANA MEDICAID PROGRAMISSUED:05/26REPLACED:09/20/21CHAPTER END STAGE RENAL DISEASE SECTION 17.1: COVERED SERVICESPAGE(S) Covered ServicesPage of Section Documenting whether the beneficiaryhas or had peritonitis that requiresphysician intervention or hospitalization (Unless there is evidence of peritonitis, a culture for peritonitis is not necessary)Inspecting the catheter siteDrawing blood sampl

esAdministering medications prescribed by the beneficiary’sphysician to treat a renal related conditionAdministering blood or blood products prescribed by the physicianProviding social services consultation and/or interventionPerforming delivery, installation, maintenance, repairand testing of the cyclerandDelivering all dialysis related suppliesEquipment and Supplies for Home DialysisProviders will be reimbursed for the covered items in accordance with the Durable Medical Equipment (DME) Program guidelines. These items must be requested by a DME provider and prior authorized by the fiscal intermediary’s Prior Authorization Unit. The DME manualprovides information on covered services and the prior authorization process. (See Appendix A for information on accessing manualsLaboratory ServicesLouisiana Medicaid reimburses ESRD pr

ovidersfor both routine and nonroutine laboratory services. oviders may contract with outside laboratories to perform these lab procedures. Routine Laboratory ServicesRoutine lab work is an integral part of outpatient hemodialysis services. Reimbursement for routine lab services is included in the dialysis reimbursement rateand cannot be billed separately by the dialysis facility nor a contracted laboratory LOUISIANA MEDICAID PROGRAMISSUED:05/26REPLACED:09/20/21CHAPTER END STAGE RENAL DISEASE SECTION 17.1: COVERED SERVICESPAGE(S) Covered ServicesPage of Section COVERED SERVICESOnly outpatient end stage renal disease (ESRD) services are covered at Medicaid enrolled freestanding ESRD centers. LOUISIANA MEDICAID PROGRAMISSUED:05/26/22REPLACED:09/20/21CHAPTER END STAGE RENAL DISEASE SECTION 17.0: OVERVIEWPAGE(S) OverviewPage of S