Dialysis Claim Payment Policy
As part of our continued efforts to ensure evidence-based guidelines are used when making medical decisions, WellCare will be implementing a new Dialysis Claims Payment Policy. Chronic kidney disease (CKD) or End Stage Renal Disease (ESRD) is a condition in which the kidneys are damaged or cannot filter blood as well as healthy kidneys. Because of this, excess fluid and waste from the blood remain in the body and may cause other health problems. When this condition occurs, it is often necessary for patients to require dialysis.
Dialysis is the process of removing waste products from the body by diffusion from one fluid compartment to another across a semi-permeable membrane. Dialysis procedures can include hemodialysis, peritoneal dialysis, hemofiltration and ultrafiltration. Of these types of dialysis procedures, two are commonly used for the treatment of ESRD: hemodialysis and peritoneal dialysis.
Hemodialysis - Blood passes through an artificial kidney machine and the waste products diffuse across a manmade membrane into a bath solution known as dialysate after which the cleansed blood is returned to the patient’s body. Hemodialysis is accomplished usually in 3 to 5 hour sessions, 3 times a week.
Peritoneal Dialysis - Waste products pass from the patient’s body through the peritoneal membrane into the peritoneal (abdominal) cavity where the bath solution (dialysate) is introduced and removed periodically. There are three types of peritoneal dialysis:
Continuous Ambulatory Peritoneal Dialysis (CAPD) - In CAPD, the patient’s peritoneal membrane is used as a dialyzer. The patient connects a 2-2.5 liter plastic bag of dialysate to a surgically implanted indwelling catheter that allows the dialysate to pour into the beneficiary’s peritoneal cavity. Every 4 to 6 hours the patient drains the fluid out into the same bag and replaces the empty bag with a new bag of fresh dialysate. This is done several times a day.
Continuous Cycling Peritoneal Dialysis (CCPD) - CCPD is a treatment modality that combines the advantages of the long dwell, continuous steady-state dialysis of CAPD, with the advantages of automation inherent in intermittent peritoneal dialysis. The major difference between CCPD and CAPD is that the solution exchanges, which are performed manually during the day by the patient on CAPD, are moved to nighttime with CCPD and are performed automatically with a peritoneal dialysis cycler. Generally, there are three to seven nocturnal exchanges over eight to ten hours. Upon awakening, the patient disconnects from the cycler and usually leaves, but not always, the last 2-2.5 liter fill inside the peritoneum to continue the daytime long dwell dialysis.
Intermittent Peritoneal Dialysis (IPD) - Waste products pass from the patient’s body through the peritoneal membrane into the peritoneal cavity where the dialysate is introduced and removed periodically by machine. Peritoneal dialysis generally is required for approximately 30 hours a week, either as three 10-hour sessions or less frequent, but longer, sessions.
WellCare reimburses providers for dialysis treatments according to the methodology below:
Criteria for CAPD/CCPD
In accordance with CMS Guidelines Chapter 8 Section 80.4 of the Medicare Claims Processing Manual updated 01/18/2019, Rev. 4202, CAPD/CCPD will be allowed to be paid on a weekly or daily basis, not on a per treatment basis. Billing instructions require providers to report the number of days in the unit’s field. A facility’s daily payment rate is 1/7 of three times the composite rate for a single hemodialysis treatment.
Criteria for Hemodialysis
To facilitate for a more standardized billing practice WellCare will move to a 6 day billing cycle versus CMS 7 day billing cycle for Hemodialysis treatments.
Additional Dialysis: If additional dialysis beyond the usual weekly maintenance dialysis due to the Member’s underlying condition, the ESRD facility’s claim for these extra services must be accompanied by a medical justification for payment to be made.