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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. This care is delivered in an outpatient setting and is designed to support the patient's ongoing dialysis treatment. The primary healthcare provider, which may include a physician or another qualified health care professional, plays a crucial role in managing the patient's dialysis regimen. This includes establishing the dialyzing cycle, conducting evaluations and management services pertinent to the dialysis process, and overseeing the patient's overall health throughout the month. The provider is responsible for routine examinations to identify and address any existing or emerging medical issues, ensuring that the dialysis services are administered according to the prescribed plan. Additionally, the healthcare professional is tasked with reviewing laboratory results, monitoring medications and nutritional supplements, and making necessary adjustments to optimize the patient's care. Coordination of care is also a key component, which may involve collaboration with social services, nutritional support, planning for kidney transplantation, and engaging with other medical or surgical specialists as required. The services associated with ESRD are encapsulated within a single code, which is billed once per month, reflecting the frequency of face-to-face visits with the patient. Specifically, CPT® Code 90962 is utilized when there is one face-to-face visit in a month, while other codes are designated for varying frequencies of visits.
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The following indications outline the circumstances under which end-stage renal disease (ESRD) related services are performed:
The procedure for providing ESRD related services involves several key steps that ensure comprehensive care for the patient:
Post-procedure care for patients receiving ESRD related services includes ongoing monitoring and follow-up to ensure the effectiveness of the dialysis treatment and the patient's overall health. Patients are expected to have regular check-ins with their healthcare provider to assess their condition, review any changes in symptoms, and adjust treatment plans as necessary. Additionally, the healthcare provider may continue to monitor medications and nutritional supplements, making modifications based on the patient's needs. It is essential for patients to maintain open communication with their healthcare team to address any concerns or complications that may arise during their treatment.
| Short Descr | ESRD SERV 1 VISIT P MO 20+ | Medium Descr | ESRD RELATED SVC MONTHLY 20&/>YR OLD 1 VISIT | Long Descr | End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 1 face-to-face visit 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. | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | GW | Service not related to the hospice patient's terminal condition | 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 | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | 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 | 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 | GT | Via interactive audio and video telecommunication systems | 24 | Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period: the physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. this circumstance may be reported by adding modifier 24 to the appropriate level of 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. | 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. | 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. | AR | Physician provider services in a physician scarcity area | FQ | The service was furnished using audio-only communication technology | G2 | Most recent urr reading of 60 to 64.9 | G3 | Most recent urr reading of 65 to 69.9 | G6 | Esrd patient for whom less than six dialysis sessions have been provided in a month | GC | This service has been performed in part by a resident under the direction of a teaching physician | SA | Nurse practitioner rendering service in collaboration with a physician | V7 | Arteriovenous fistula only (in use with two needles) | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | 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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