# Hospital Service in Same Month for ESRD Patient



## ABridgman (Sep 2, 2013)

Doctor saw a patient in the hospital in the same month as the "once a month" code 90960 was billed.

Medicare rejected the two service dates for 99233 for reason B-15 - not paid seerately and Remark M80 - Same date of service.

It would seem they bundeled the once-a-month code 90960 with the two 99233 services, which had NOTHING to do with his ESRD condition.

No ESRD diagnosis codes are used in the hospital followup (99233) visits.

I'm thinking that the AY Modifier should have been used to bill this, so that the claim would have paid.  Am I correct on this?


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## LSchepker1 (Sep 2, 2013)

Hello, The information below is pasted from the internet. I just started with Google and it took me to WPS Medicare which was my carrier when I billed dialysis for IL physicians. Inpatient hospital visits should be separately payable for a monthly dialysis pt. Any type of outpatient or observation is not based on my understanding of this. Hope this helps.




Providers must ensure that all face-to-face encounters with the patient are documented and that the appropriate procedure code is billed based on the number of face-to-face visits that have occurred during that month. For more information on proper billing and documentation of these services refer to CMS Internet-Only Manual, Publication 100-02, Chapter 11Adobe Portable Document Format, Section 80.2 - Physicians' Services - Outpatient Maintenance Dialysis.

Medicare Benefit Policy Manual
Chapter 11 - End Stage Renal Disease (ESRD)

80.1 - Physicians' Services to an ESRD Inpatient
(Rev. 1, 10-01-03)
B3-2230.4
Physicians' services furnished to ESRD patients, who require inpatient hospital care in connection with the renal condition or any other condition, are covered if the carrier determines the services to be reasonable and necessary. Inpatient physician's visits are covered in addition to the composite rate or MCP amount.


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## ABridgman (Sep 2, 2013)

Thanks.
But your documentation says "In connection with the renal condition...OR ANY OTHER CONDITION."

Yet, in my case, Medicare rejected it.
And in my case, the hospital services are NOT related to the renal conition.

so it should have paid, even without a modifier...according to what you're saying.

However, this is not what happened.


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## ABridgman (Sep 5, 2013)

OK...I actually spoke with someone at Medicare about this one.

The hospital claims should have been filed with a 25 Modifier.


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