Since the Bundle was implemented on January 1, the number of ESRD billing questions has exploded. Sometimes it takes weeks to obtain answers from Medicare and there are many issues that are unclear or overlooked. My hope is this column can provide you with information to assist you in billing accurately and staying in compliance with laws and regulations.
Q: I have a catheter patient that showed me a letter from a supply company stating that our dialysis facility should now provide the patient with expensive waterproof dressings free of charge. Is that correct?
A: Patients with a new catheter often benefit from waterproof dressings that help to prevent infection. These dressings are routinely ordered by physicians and prior to January, supply companies billed Medicare for these dressings. However, since the beginning of the year, supply companies have received denials for their claims. As part of the denial, Medicare cites Change Request 7312, which modified the items that fall under the Composite Rate to specifically include waterproof catheter dressings.
Some supply companies seized upon the wording in the Change Request and sent letters to their customers stating that their dialysis facility should now provide these dressings to their patients free of charge. Of course, this was a big surprise to facility administrators, especially if the facility was not involved in ordering these dressings for their patients. Facility staff across the country have been placed in awkward positions with their patients who suddenly expect the facility to provide and pay for waterproof dressings.
The Change Request includes the following statement, which is part of the Composite Rate section of the Medicare Benefit Policy Manual, “Items and services included under the composite rate must be furnished by the facility, either directly or under arrangements to all of its dialysis patients.”
Some medical supply companies seized on the use of the word “must” to justify their contention that facilities should now provide these dressings to their patients free of charge. A facility that contacted me said one of their patients thought the facility was now required to provide these free of charge as long as the patient requested it.
However, the Change Request also includes the following statements, “ESRD facilities and Monthly Capitated Payment (MCP) Physicians and practitioners may determine that it is medically required for a dialysis patient to use dressings or protective access coverings, including catheter coverings on their access site…To the extent that dressings and protective access coverings, including catheter coverings, are determined to be medically required, an ESRD facility can provide them.”
Note that nothing in these comments indicates that a facility is required to provide these dressings unless a determination has been made by the facility or a physician that they are required for the patient.
In the past, a physician may have ordered the dressings giving little thought as to who would pay for them since the medical supply companies could be reimbursed by Medicare. Today, it is important for ESRD facilities to communicate with physicians ordering these dressings and to coordinate their efforts so they can together determine if dressings should be “medically required” for catheter patients. If it is determined by the physician or the facility that the dressings are required, the facility must provide them to the patient without receiving any additional reimbursement from Medicare.
Q: Lab billing is really confusing to me. Where do I go for help?
A: When billing Medicare, Medicare’s manuals contain instructions and guidance for billing all items required to be on a dialysis claim and should be consulted for guidance and direction. However, instructions are sometimes scattered between several manuals and can be difficult to locate. Further, the instructions are sometimes ambiguous and are subject to some degree of interpretation by each Medicare contractor.
Thus, other sources can help clarify and explain some of the most common ESRD lab billing issues. One of the best sources is your laboratory company. If you use one of the national companies, they have their own billing department that was billing Medicare for all of your labs prior to January 1. They can be a valuable resource and your laboratory sales rep is often happy to put you in contact with their billing personnel.
However, as is the case with any source, lab companies are not infallible. I discovered that even the major lab companies differ in how they bill for some labs so their information should be used for guidance and not as an absolute authority.
CMS has a helpful FAQ section in which you can look up answers to questions. The link is http://questions.cms.hhs.gov. Type your question or topic into the search window and click on the “Search” button for results. While this site contains many helpful answers, the wording you type into the search window can yield vastly different results. Also, the answer to your specific question may not be found on the site. You can submit your question to CMS, but it takes some time for a response to be generated.
Talking with billing personnel at other facilities can also be helpful. However, proceed with great caution and try to verify with your Medicare contractor any directions you receive.
Of course, your Medicare contractor can be an excellent resource for answering your questions. They are also good about informing you about Local Coverage Determinations (LCD’s) that are specific to them. All Medicare contractors offer teleconferences and webinars that can be helpful in keeping you informed. However, the conferences and webinars are often pretty general and your specific issue may not be addressed. You can always submit a question to your contractor, but as most of you know it can take weeks to receive an answer and the answer may not be clear or in some cases could even be incorrect.
So how do you know what to do? Checking multiple sources is best and verifying the information with your Medicare contractor is always wise. If you are audited, you may need to explain why you billed the way you did, so always keep a record of the sources that guide your work.
NOTE: The information contained in this column is for informational purposes only and is not to be construed as payer policy or procedures. You should always verify information in this column with appropriate government or payer manuals and instructions and proceed as directed by your Medicare contractor or other appropriate payer representatives.
Rick Collins is the Chief Operating Officer of Sceptre Management Solutions, Inc., a company that specializes in billing for outpatient dialysis facilities in the U.S.
