Yesterday, the OIG issued their monthly Work Plan update, which now includes monthly End-stage renal disease (ESRD) related visits. As a result of a Comprehensive Error Rate Testing (CERT) review of ESRD related services, the program found that almost one-third of the payments were improper. Common errors included insufficient documentation or no documentation and incorrect coding.

A physician/practitioner that manages a patient a patient’s dialysis services is paid a monthly capitation payment based on the number of visits and age of the patient. The CPT code ranges for monthly ESRD related services are 90951-90966.  The documentation must include a signed practitioner order and a complete visit note for each face-to-face visit during the billing period. Only the physician who provides the complete assessment, establishes the patient’s plan of care and provides the ongoing management should submit the monthly claims for ESRD related services.  Home dialysis visits also have specific requirements.

Based on the CERT findings, the OIG will now review whether monthly ESRD related visits were billed properly.

If your organization provides and bills for ESRD monthly visits, we recommend conducting a proactive audit designed to address the common documentation and coding deficiencies that were noted within the CERT findings and will be the focus of the OIG audits.

The complete Work Plan can be found at: https://oig.hhs.gov/reports-and-publications/workplan/

Several CMS contractors, including CGS,  have issued helpful fact sheets on ESRD related services. You can locate the CGS fact sheet at:  https://www.cgsmedicare.com/partb/mr/pdf/esrd.pdf

The Medicare Claims Processing Manual, chapter 8, provides detailed information regarding Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier claims and can be found here:  https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c08.pdf