Healthcare Common Procedure Coding System (HCPCS) Procedure Codes and Applicable Diagnosis Codes
Effective for services performed on and after January 1, 2010, the following new HCPCS codes have been created for KDE services when provided to patients with stage IV CKD.
• G0420: Face-to-face educational services related to the care of chronic kidney disease; individual, per session, per one hour
• G0421: Face-to-face educational services related to the care of chronic kidney disease; group, per session, per one hour When billing for KDE services the applicable ICD diagnosis code shall be used:
Billing Requirements for Coverage of Kidney Disease Patient Education Services
Effective for claims with dates of service on and after January 1, 2010, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) determines that kidney disease patient education services are covered when provided to patients with stage IV chronic kidney disease (CKD). See Pub. 100-02, chapter 15, section 310, for complete coverage guidelines.
Contractors shall pay for kidney disease education (KDE) services that meet the following conditions:
• No more than 6 sessions of KDE services are provided in a lifetime,
• Is provided in increments of 1 hour. In order to bill for a session, a session must be at least 31 minutes in duration. A session that lasts at least 31 minutes, but less than 1 hour still constitutes 1 session.
• Is provided either individually or in a group setting of 2 to 20 individuals who need not all be Medicare beneficiaries.
• Furnished, upon the referral of the physician managing the beneficiary’s kidney condition, by a qualified person meaning a:
o physician, physician’s assistant, nurse practitioner, or clinical nurse specialist;
o hospital, critical access hospital (CAH), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF), home health agency (HHA), or hospice, that is located in a rural area, or
o hospital or CAH that is paid as if it were located in a rural area (hospital or CAH reclassified as rural under section 42 CFR 412.103).
NOTE: A renal dialysis facility (Type of Bill (TOB) 72x) is precluded from providing KDE services.
Revenue code 0942 should be reported when billing for KDE services in the following: SNFs, HHAs, CORFs, hospices, and CAHs.
Hospital outpatient departments bill for this service under any valid/appropriate revenue code. They are not required to report revenue code 0942.
Hospices report this service on a separate claim from any hospice services. Hospice claims billed for revenue code 0942 that contain any other services will be returned to the provider. In addition, hospices report value code 61 or G8 when billing for KDE services.
NOTE: KDE services are not covered when services are submitted on TOB 72X.
PROVIDER ACTION NEEDED
Change Request (CR) implements requirements for billing modifier GT for Telehealth Distant Site Services. As of January 1, 2018, the GT modifier is only allowed on institutional claims billed by a Critical Access Hospital (CAH) Method II. Make sure your billing staffs are aware of this requirement.
BACKGROUND
Previous guidance instructed providers to submit claims for telehealth services using the appropriate procedure code along with the telehealth modifier GT (via interactive audio and video telecommunications systems). In the Calendar Year (CY) 2017 Physician Fee Schedule (PFS) final rule, payment policies regarding Medicare’s use of a new Place of Service (POS) Code describing services furnished via telehealth (POS 02) were finalized and implemented through CR9726. The new POS code became effective January 1, 2017.
In the CY 2018 PFS final rule, the requirement to use the GT modifier was eliminated for all professional claims. CR10152, which implemented that policy, included a business requirement instructing MACs to be aware that the GT modifier is only allowed for distant site services billed when the type of bill is a Method II CAH with a revenue code 96X, 97X, or 98X or with a service line that contains HCPCS code Q3014 or the type of bill is a Method II CAH with revenue code 942 and contains G0420 or G0421. As of January 1, 2018, the GT modifier is only allowed on institutional claims billed under CAH Method II. If the GT modifier is billed under any
circumstances, except as just outlined for Method II CAHs, the claim line will be rejected with the following remittance codes:
• Group Code CO - Contractual obligation
• Claim Adjustment Reason Code 4 - The procedure code is inconsistent with the modifier used or a required modifier is missing. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 07/01/2017
• Remittance Advice Remarks Code N519 - Invalid combination of HCPCS modifiers.
• If ICD-9-CM is applicable, ICD-9-CM - 585.4 (chronic kidney disease, Stage IV (severe)), or
• If ICD-9-CM is applicable, ICD-10-CM – N18.4 (Chronic Kidney Disease, stage 4.
NOTE: Claims with HCPCS codes G0420 or G0421 and ICD-9 code 585.4, if applicable, or, if ICD -10 is applicable, ICD-10 code
N18.4 that are billed for KDE services are not allowed on a professional and institutional claim on the same service date.
Medicare Summary Notices (MSNs) and Claim Adjustment Reason Codes (CARCs)
The following messages are used by Medicare contractors when denying non-covered services associated with KDE services when provided to patients with stage IV CKD:
When denying claims for KDE services billed without diagnosis code 585.4 contractors shall use:
• MSN 16.10 - Medicare does not pay for this item or service.
• CARC 167 - This (these) diagnosis(es) is (are) not covered. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
When denying claims for KDE services when submitted for more than 6 sessions contractors shall use:
• MSN 15.22 - The information provided does not support the need for this many services or items in this period of time so Medicare will not pay for this item or service.
• CARC 119 - Benefit maximum for this time period or occurrence has been reached.
When denying claims for KDE services when two claims are billed (professional and institutional) on the same service date, contractors shall use:
• MSN 15.5 – The information provided does not support the need for similar services by more than one doctor during the same time period.
• CARC 18 – Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO).
A/B MACs (A) shall deny KDE services when rendered in an urban area unless:
• The provider is a hospital on the section 401 list or
• The claim is submitted on TOB 85X.
A/B MACs (A) shall deny payment for KDE services when submitted on TOB 72X.
Use the following messages:
• MSN 21.6 – This item or service is not covered when performed, referred or ordered by this provider.
• CARC 170 – Payment is denied when performed/billed by this type of provider in this type of facility. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Advance Beneficiary Notice (ABN) Information
If a signed ABN was provided, contractors shall use Group Code PR (Patient Responsibility) and the liability falls to the beneficiary.
If an ABN was not provided, contractors shall use Group Code CO (Contractual Obligation) and the liability falls to the provider.
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