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End-stage renal disease (ESRD) related services encompass a comprehensive range of medical care provided to patients aged 20 years and older who are experiencing advanced kidney failure. These services are delivered on a monthly basis in an outpatient setting and are designed to manage the complexities associated with dialysis treatment. The physician or other qualified health care professional plays a critical role in establishing the patient's dialysis regimen, which includes determining the appropriate dialyzing cycle tailored to the individual's needs. Throughout the month, the healthcare provider conducts face-to-face evaluations and management services, ensuring that the patient receives the necessary oversight during their dialysis sessions. This includes routine examinations to monitor for existing health issues and to identify any new symptoms that may arise. The healthcare professional is responsible for ensuring that dialysis treatments are administered as prescribed, making any necessary adjustments to the dialysis prescription based on the patient's condition and laboratory results. Additionally, the provider monitors the patient's medications and nutritional supplements, making modifications as required to optimize the patient's health. Coordination of care is also a vital component of ESRD services, which may involve collaboration with social services, nutritional support, and planning for potential kidney transplant options, as well as referrals to other medical or surgical specialists when needed. The coding for these services is structured to reflect the frequency of face-to-face visits, with specific codes assigned based on the number of visits per month, thereby facilitating accurate billing and reimbursement for the comprehensive care provided to ESRD patients.
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The following indications outline the circumstances under which end-stage renal disease (ESRD) related services are performed for patients aged 20 years and older:
The procedure for providing ESRD related services involves several key steps that ensure comprehensive management of the patient's condition:
Post-procedure care for patients receiving ESRD related services includes ongoing monitoring and evaluation of the patient's health status. Patients are expected to continue regular follow-up visits to assess their response to dialysis and any adjustments made to their treatment plan. The healthcare provider remains available for telephone consultations to address any concerns or complications that may arise between visits. Additionally, the coordination of care may involve referrals to other specialists as needed, ensuring that the patient receives comprehensive support throughout their treatment journey. Regular review of laboratory results and medication management is essential to maintain optimal health and prevent complications associated with ESRD.
| Short Descr | ESRD SRV 2-3 VSTS P MO 20+ | Medium Descr | ESRD RELATED SVC MONTHLY 20/>YR OLD 2/3 VISITS | Long Descr | End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 2-3 face-to-face visits by a physician or other qualified health care professional per month | Status Code | Active Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Items and Services Not Billable to the MAC | Type of Service (TOS) | 1 - Medical Care | Berenson-Eggers TOS (BETOS) | P9A - Dialysis services (Medicare Fee Schedule) | MUE | 1 | CCS Clinical Classification | 227 - Other diagnostic procedures (interview, evaluation, consultation) |
| 95 | Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system. | X2 | Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | GW | Service not related to the hospice patient's terminal condition | CR | Catastrophe/disaster related | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | SA | Nurse practitioner rendering service in collaboration with a physician | GC | This service has been performed in part by a resident under the direction of a teaching physician | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | GT | Via interactive audio and video telecommunication systems | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | UJ | Services provided at night | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 25 | Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 77 | Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 93 | Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system : synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located away at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. | AO | Alternate payment method declined by provider of service | AR | Physician provider services in a physician scarcity area | CS | Cost-sharing waived for specified covid-19 testing-related services that result in and order for or administration of a covid-19 test and/or used for cost-sharing waived preventive services furnished via telehealth in rural health clinics and federally qualified health centers during the covid-19 public health emergency | G1 | Most recent urr reading of less than 60 | G3 | Most recent urr reading of 65 to 69.9 | G4 | Most recent urr reading of 70 to 74.9 | G6 | Esrd patient for whom less than six dialysis sessions have been provided in a month | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | KX | Requirements specified in the medical policy have been met | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | PO | Excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | U7 | Medicaid level of care 7, as defined by each state | V6 | Arteriovenous graft (or other vascular access not including a vascular catheter) | V7 | Arteriovenous fistula only (in use with two needles) | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2013-01-01 | Changed | Description Changed |
| 2011-01-01 | Changed | Short description changed. |
| 2009-01-01 | Added | - |
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