HI 00610.330 Physician's Services for ESRD
Payment for physicians' services generally is subject to the guidelines in HI 00610.030. Basically, physicians' services rendered to a renal dialysis patient are covered if determined to be reasonable and necessary. Physicians may elect to receive from the carrier a comprehensive monthly payment computed in accordance with a standard formula for their services rendered in connection with complicated and uncomplicated sessions for outpatients who are on maintenance dialysis in a facility or at home.
Where physicians have not elected the comprehensive monthly payment, their supervisory services customarily provided for maintenance dialysis patients in outpatient dialysis facilities (see below) are covered as a facility service component of the dialysis session. The intermediary reimburses the dialysis facility. Any additional physicians' services rendered to dialysis patients (see B., D., and E. below) are reimbursable by the carrier on a reasonable charge basis. These include physicians' services rendered to patients who are self-dialyzing either in an outpatient dialysis facility or at home. The following sections explain coverage primarily where the physician has not elected the monthly payment plan.
B. Physicians' services to an inpatient
Whether or not physicians have elected the comprehensive monthly payment, their services rendered to ESRD patients who require inpatient hospital care in connection with the renal condition or any other condition, are covered if they are determined to be reasonable and necessary. These physicians' services are reimbursed on a reasonable charge basis for each service rendered to the inpatient. However, where the patient was admitted for hospitalization for no reason other than to receive maintenance renal dialysis, the dialysis is considered an outpatient service and is covered by the intermediary payment made for each out patient dialysis treatment (or, with respect to physicians' supervisory services, by the comprehensive monthly payment, if applicable).
C. Physicians' services—outpatient maintenance dialysis in a facility
Where the physician has not elected the comprehensive monthly payment, it is necessary to distinguish supervisory services, reimbursable through the facility by the intermediary from certain direct patient care services (see D. below) which are reimbursable by the carrier; physicians' administrative services are reimbursable by the intermediary as a facility cost.
1. Supervisory services
Supervisory services for patients who are receiving outpatient maintenance dialysis in a facility (provider or nonprovider) are those physicians' services which are related to the care of the patient and the need for medical management over the period of time the patient is on maintenance or training dialysis. They are nonepisodic services which are furnished during the dialysis session; they reflect the facility's responsibility to provide that its services be under the general supervision of a physician. Where the physician has not elected the comprehensive monthly payment, these services are considered a facility service and must be included as a component of the facility cost or charge for the dialysis.
2. Administrative services
Another component of the facility's cost or charge for dialysis is for “administrative services” rendered by physicians. Administrative services are differentiated from “supervisory services” and other physicians' services related to patient care because they are not related directly to the patient's care but inure to the benefit of all patients as a whole and to the benefit of the facility. The administrative type of physician's service attributable to each dialysis, for accounting purposes, is easily identified since it involves services directly related to the support of the facility. Examples of such services include staff training, participating in management of the facility, advice on and procurement of facility equipment and supplies, supervision of staff for other than direct patient care and staff conferences.
D. Physicians' services related to patient care other than “Supervisory Services”
Where the physician has not elected the comprehensive monthly payment, otherwise covered patient-care services of a nonsupervisory nature are reimbursable on a reasonable charge basis. Generally, they include but are not limited to, the following kinds of services: monthly and semiannual examinations, treatment of medical disabilities associated with renal disease, such as hypotension and hypertension—including acute medical emergencies, as well as incidental diagnosis and treatment of other acute and chronic medical conditions; administration of blood; insertion of fistula needles in difficult cases; shunt cannula declotting; and management during the dialysis procedure of medical problems which are not necessarily related to the dialysis process or to renal disease.
When bills are submitted for such physicians' personal services, the carrier requires medical documentation of their necessity. Bills for physicians' personal services in connection with maintenance dialysis are not allowed without clear evidence of medical necessity.
E. Physician service during self-dialysis training
Whether or not physicians have elected the comprehensive monthly payment for services rendered to patients on maintenance dialysis, the physicians will be reimbursed for their bills submitted for services rendered to dialysis patients undergoing self-dialysis training with a flat fee of up to $500 for the course of training per patient under his supervision during the training course. (The deductible and coinsurance apply.) This payment will be made upon completion of the training course, and in addition to the monthly payment if elected, or the payment made to facilities for maintenance dialysis sessions. Where the training period is not completed, such as when the patient can no longer be trained, the reimbursement will be proportionate to the time spent in training.
All physicians' services required to create the capacity for self-dialysis are covered by the fee.
Direction of and participation in training of dialysis patients.
Review of family and home status and environment and counseling and training of family members.
Review of training progress.