Medicare and GHP reimbursement


Hello Beth,
I have a dialysis center, which provided Home Hemodialysis. some dialysis patients who have Medicare as primary and GHP as secondary. GHP would pay for Staff assisted HHD, nursing time (rev Code 0825) and equipments etc., if medicare denies the payment for nursing services, after paying composite rate for hemodialysis (Rev code 0821). Please advice HCPCS codes acceptable to medicare as non-covered services, which could be further billed to commercial payor, if a denial is shown in Medicare EOB. Currently our claims are being rejected by medicare, if the UB-04 has both HD composite billing and nursing care.
Thank you
B. Gupta


The Medicare Benefit Policy Manual, Chapter 11, Section 30.1-Home Dialysis Items and Services includes this information:

[SIZE=3][SIZE=3]C. Staff Assisted Home Dialysis

Effective January 1, 2011, renal dialysis services for patients receiving home dialysis may only be billed under Method I. Staff-assisted home dialysis using nurses to assist ESRD beneficiaries is not included in the ESRD PPS and is not a Medicare covered service.

If an entity wishes to bill Medicare for a non-covered ESRD-related service they provide to Medicare beneficiaries, they must first enroll with the appropriate Medicare contractor (assuming that Medicare recognizes such type of provider/supplier for billing purposes). Providers/suppliers must enroll in the jurisdiction(s) where they intend to provide services and follow the jurisdiction rules specified in Pub. 100-04, chapter 1, ยง10.

Once the ESRD facility is enrolled with the appropriate Medicare contractor(s), they should work with the contractor(s) to determine the appropriate code to bill for the service, if any. Finally, entities enrolled in Medicare as Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) suppliers may not bill the DME MACs for professional or quasi-professional services, including but not limited to nurse caregiver staff-assistance services. Instead, if a DMEPOS supplier is permitted under State law to furnish such services under its licensure and wishes to bill Medicare for such services, it must enroll with the appropriate Medicare contractor under such professional or quasi-professional service category as Medicare may recognize for Medicare billing purposes, if any.

For additional information, contact your appropriate Medicare contractor."