Coding Cues: Payment for ESRD-related services

July 4, 2008

Our multispecialty group recently added a nephrologist, and our staff members are unsure of how to bill for her services. Can you provide some guidance on how to handle capitated and partial month end-stage-renal disease (ESRD)?

Key Points

Our multispecialty group recently added a nephrologist, and our staff members are unsure of how to bill for her services. Can you provide some guidance on how to handle capitated and partial month end-stage-renal disease (ESRD)?

Direct your staff to CMS' Medicare Claims Processing Manual 100-04, which defines the HCPCS codes to be used when billing for ESRD services in Chapter 8, Section 140: Monthly Capitation Payment Method for Physicians. The section is broken down into 140.1-Payment for ESRD-related services under the monthly capitation payment (for center-based patients); Section 140.1.1-Payment for Managing Patients on Home Dialysis; Section 140.1.2-Patients Who Switch Modalities (center to home and vice versa); and Section 140.2-Payment for ESRD-Related Services Per Diem, and continues through Section 104.5.1. Each subsection specifies which codes to use, based on the patient's age and number of monthly visits. To bill for a patient over the age of 20 with four or more visits per month, for instance, you'd use G0317; if that patient had two to three visits, you'd use G0318, and a single visit would be billed with G0319.