CAPD/CCPD provided to a hospital outpatient, by a facility with an ESRD certified dialysis clinic

goodjegoodje
in BILLING AND CLAIMS

I'm looking for guidance on billing CAPD/CCPD services (revenue codes 084X/085X) performed during a patient's hospital outpatient stay (observation / ambulatory surgery) by a hospital that does have a certified ESRD clinic.

Specifically we're looking at the condition codes, as only 73 (training) and 74 (home) are accepted for the CAPD/CCPD revenue codes, but there is no training/retraining involved, and the service is being performed in the hospital instead of at home. These patients are typically home for their treatments, but for a day or two have their treatment performed in the facility, while they're there for other services.

This chart is from an older MAC webinar on ESRD, but the scenario in question wasn't discussed. The condition code we expected to use, 76- back up in facility, causes the claim to be rejected.

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Comments

  • RHirschRHirsch

    Not that I know what I am talking about but this document pn page 3 says use 76

    https://www.cms.gov/files/document/finalchap5pdf#:~:text=084X%20Continuous%20Ambulatory%20Peritoneal%20Dialysis,peritoneal%20membrane%20as%20a%20dialyzer.

    I don't think your chart means those are the only ones that can be used, just the common ones.

  • goodjegoodje

    Thanks for the response Dr. Hirsch.

    *Sharing our resolution, in case anyone else comes across this issue later.*

    I thought so too initially, that the condition code matches were just common ones, but there are edits (at least for our MAC - First Coast) that go with the chart. We did get some help from them late Friday though. They said that because the patient is in the facility it's considered an interruption to the continuous treatment/ consecutive sessions, and recommended it as a one-off under 082X/083X with the 76.

    Reason code 36112: ONE OF THE FOLLOWING CONDITION CODES IS PRESENT ON AN ESRD CLAIM CONTAINING EITHER A REVENUE CODE 841, OR A REVENUE CODE 851: 71 - FULL CARE IN UNIT; 72 - SELF CARE IN UNIT; 76 - BACK-UP IN-FACILITY DIALYSIS.

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