Medicare dialysis billing manual

The department shall not reimburse for a service provided to a beneficiary by more than one provider, of any program in which the same service is covered, during the same time period. Each MCO provides prior authorization for its beneficiaries. Each MCO processes its own claims. Kentucky Medicaid requires the use of ICD codes on all claims submitted for reimbursement. Kentucky Medicaid requires the use of CMS billing forms. The request must include the reason for the request along with a hard copy claim.

Claims must be received within 12 months from the date of service DOS or 6 months from the Medicare pay date whichever is longer, or within 12 months from the last Kentucky Medicaid denial.

Main Content. In order to enroll and bill Kentucky Medicaid, a Renal Dialysis Centers service providers must be: a hospital unit which must be approved by Medicare Licensed in Kentucky or the state in which they participate.

Renal Dialysis Centers must be licensed with the Office of Inspector General, Division of Health Care Enrolled as a Kentucky Medicaid provider, and if applicable, enrolled with the Managed Care Organization MCO of any beneficiary it provides services for Must have a physician medical director, responsible for supervising the staff of the facility, who must be a nephrologist, internist, or pediatrician with at least 12 months experience or training in the treatment and management of end-stage renal disease ESRD patients.

The medical director shall be a full or part-time staff member and must be "immediately available" if not on-site in the facility A hospital does not need to provide renal transplantation to qualify as a renal dialysis center.

Covered Services What are Renal Dialysis services? How do I verify eligibility? Reimbursement The Renal Dialysis facility must be able to bill all third-party payers and furnish the full spectrum of diagnostic, therapeutic, and rehabilitative services required for the care of ESRD dialysis patients including inpatient dialysis furnished directly or indirectly under arrangement.

Duplication of Service The department shall not reimburse for a service provided to a beneficiary by more than one provider, of any program in which the same service is covered, during the same time period.

Optional Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice RA. Optional Enter the number assigned to the member to assist in retrieval of medical records. Enter the three-digit number indicating the specific type of bill.

The three-digit code requires one digit each in the following sequences Type of facility, Bill classification, and Frequency : Digit 1. Other for hospital referenced diagnostic services or home health not under a plan of treatment. Required This form locator must reflect the beginning and ending dates of service.

When span billing for multiple dates of service and multiple procedures, complete FL 45 Service Date. Providers not wishing to span bill following these guidelines, must submit one claim per date of service. All line item entries must represent the same date of service. Example: for January 1, Conditional Complete with as many codes necessary to identify conditions related to this bill. Conditional Complete both the code and date of occurrence.

Enter the appropriate code and the date on which it occurred. Occurrence Codes: 1. Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer A indicated in FL Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer B indicated in FL Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer C indicated in FL Conditional Enter appropriate codes and related dollar amounts to identify monetary data or number of days using whole numbers, necessary for the processing of this claim.

Never enter negative amounts. Codes must be in ascending order. If a value code is entered, a dollar amount or numeric value related to the code must always be entered. Most Common Codes: Accident Hour Enter the hour when the accident occurred that necessitated medical treatment.

Use the same coding used in FL 18 Admission Hour. Required Enter the revenue code which identifies the specific service provided. List revenue codes in ascending order. These codes are listed in Appendix Q, under the Appendices drop-down section on the Billing Manuals web page , for valid dialysis revenue codes.

A revenue code must appear only once per date of service. Complete with as many codes necessary to identify conditions related to this bill. Required Enter the revenue code description or abbreviated description. Example: 42 REV. Use approved modifiers listed in this section for hospital based transportation services. Complete for laboratory, radiology, physical therapy, occupational therapy, and hospital based transportation.

The only valid modifier for OP radiology is TC. With the exception of outpatient lab and hospital- based transportation, outpatient radiology services can be billed with other outpatient services. Combine the units in FL 46 Units to report multiple services. Each date of service must fall within the date span entered in the "Statement Covers Period" field FL 6. Required Enter a unit value on each line completed.

Use whole numbers only. Do not enter fractions or decimals and do not show a decimal point followed by a 0 to designate whole numbers e. For span bills, the units of service reflect only those visits, miles or treatments provided on dates of service in FL Required Enter the total charge for each line item.

Calculate the total charge as the number of units multiplied by the unit charge. Do not subtract Medicare or third-party payments from line charge entries. Do not enter negative amounts. A grand total on line 23 is required for all charges. Conditional Enter incurred charges that are not payable by the Health First Colorado. Each column requires a grand total on line Non-covered charges cannot be billed for outpatient hospital laboratory or hospital based transportation services.

Required Enter the payment source code followed by name of each payer organization from which the provider might expect payment. At least one line must indicate Health First Colorado. Source Payment Codes. Required Enter the NPI number assigned to the billing provider. Payment is made to the enrolled provider or agency that is assigned this number.

Conditional Complete when there are Medicare or third-party payments. Enter the net amount due from Health First Colorado after provider has received other third party, Medicare or member liability amount.

Medicare Crossovers Enter the sum of the Medicare coinsurance plus Medicare deductible less third-party payments and member payments. Required Enter the member's name on the Health First Colorado line. Enter the policyholder's last name, first name, and middle initial. Required Enter the insured's unique identification number assigned by the payer organization exactly as it appears on the health insurance card.

Include letter prefixes or suffixes shown on the card. Conditional Complete when there is third party coverage. Enter the name of the group or plan providing the insurance to the insured exactly as it appears on the health insurance card.

Enter the identification number, control number, or code assigned by the carrier or fund administrator identifying the group under which the individual is carried.

Conditional Complete when the service requires a PAR. Enter the name of the employer that provides health care coverage for the individual identified in FL 58 Insured Name. Submitted information is not entered into the claim processing system.

Optional Enter the exact diagnosis code corresponding to additional conditions that co-exist at the time of admission or develop subsequently and which effect the treatment received or the length of stay.

Do not add extra zeros to the diagnosis code. Optional Enter the diagnosis code for the external cause of an injury, poisoning, or adverse effect. This code must begin with an "E". Conditional Enter the ICDCM procedure code for the principal procedure performed during this billing period and the date on which procedure was performed. Apply the following criteria to determine the principle procedure: The principal procedure is not performed for diagnostic or exploratory purposes.