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Internal Medicine Coding Alert

Reader Question:

Dialysis Billing Guidelines

Published on Fri Feb 01, 2002

Question: What are the guidelines for billing dialysis? Do the rules for teaching assistants apply? The physicians in our nephrology division insist that the use of higher-level dialysis codes (90937) is not dependent on the number of visits made to the patient, but on the intensity of the care or the instability of the patient. They claim they often know before starting dialysis if the person is unstable. They believe a higher level of coding is warranted because of time spent in telephone contact with the nurses and residents even though they see the patient only once. They say multiple visits have nothing to do with the billing.

Iowa Subscriber
 
Answer: The doctors have a point. The intensity of the care and the instability of the patient do affect coding. However, you are also correct in stating that to report 90937 (hemodialysis procedure requiring repeated evaluation[s] with or without substantial revision of dialysis prescription) multiple physician visits to evaluate the patient on the same day are required.
 
CPT 2001 states that 90937 is reported when it is necessary for the physician to re-evaluate the patient during the hemodialysis procedure. Also, when appropriate, prolonged services codes 99356-99357 may be reported separately. Code 99356 is prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service for the first hour (list separately in addition to code for inpatient E/M service). Code 99357 is for each additional 30 minutes (list separately in addition to code for prolonged physician service). Critical care codes 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (... each additional 30 minutes [list separately in addition to code for primary service]) may also be reported separately. The need for repeat evaluations rests with the physicians clinical judgment.
 
According to Medicares Final Rule published in the December 1994 Federal Register, 90937 may be reported when the physician sees the patient two or more times per day during the dialysis procedure because of significant dialysis-related problems or other significant acute medical conditions. These separate visits must be clearly documented in the progress notes to receive proper reimbursement.
 
You are also correct that the teaching-physician guidelines apply in this instance. That is, the teaching physician must personally perform the key portions of any service provided by a resident. In this example, the teaching physician would need to be present for the initial evaluations and re-evaluations. Phone contact between teaching physician and the resident or other ancillary staff (nurses, fellows, etc.) could not be counted.

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