Below is an overview of the most common billing requirements; it is not meant to be all-inclusive. There may be other ESRD-related services that are billed using codes that may not be reflected here.
Type of bill acceptable codes for Medicare are:
Type of bill |
Definition |
721 |
Admit through discharge claim - This code is used for a bill encompassing an entire course of outpatient treatment for which the provider expects payment from the payer. |
722 |
Interim - first claim - This code is used for the first of an expected series of payment bills for the same course of treatment. |
723 |
Interim - continuing claim - This code is used when a payment bill for the same course of treatment is submitted, and further bills are expected to be submitted later. |
724 |
Interim - last claim - This code is used for a payment bill which is the last of a series for this course of treatment. The “Through” date of this bill (FL 6) is the discharge date for this course of treatment. |
727 |
Replacement of prior claim - This code is used when the provider wants to correct (other than late charges) a previously submitted bill. The previously submitted bill needs to be resubmitted in its entirety, changing only the items that need correction. This is the code used for the corrected or “new” bill. |
728 |
Void/cancel of a prior claim - This code indicates this bill is a cancel-only adjustment of an incorrect bill previously submitted. Cancel-only adjustments should be used only in cases of incorrect provider identification numbers, incorrect Medicare beneficiary identifier, duplicate payments, and some OIG recoveries. For incorrect provider numbers or Medicare beneficiary identifier, a corrected bill is also submitted using a code 721. |
The beginning and ending service dates of the period should be included on one bill. Note: ESRD services are subject to the monthly billing requirements for repetitive services.
The statement covers 'from' and 'through' dates must reflect the first day dialysis began in the billing month through the last day of dialysis in the billing month.
Example: 1/03-1/27, not 1/01-1/31
Line-item detail billing is required for ESRD claims. Each service must be submitted on a separate line with the appropriate line-item date of service. The Medicare standard systems perform line-item date of service compare for ESRD claims with statement billing periods overlapping the statement billing period of another processed claim. This prevents monthly claims from receiving overlapping edits based on the statement billing period dates but rather, only when the ESRD claim has a line item that duplicates another processed claim.
Report a principal diagnosis and any other diagnosis codes for co-morbidity conditions (if applicable).
The lists of the comorbidity categories and diagnosis codes are found on the CMS website in the ESRD PPS patient-level adjustments site under downloads:
ESRD PPS Comorbidity Categories and Diagnostic Codes
ESRD claims must have one dialysis condition code (CC) per claim to describe the dialysis setting. If two dialysis settings are used during the month, then two claims must be filed. It is recommended to submit each claim for the full range of dates of service that are applicable to each type of dialysis through each last day of dialysis that was performed in the billing month.
Condition code * |
Definition |
71 |
Full care in unit or transient |
72 |
Self-care in unit |
73 |
Training |
74 |
Home |
76 |
Backup in-facility dialysis |
Condition code * |
Definition |
59 |
Non-primary ESRD facility |
70 |
Self-administered anemia management drug (EPO) |
80 |
ESRD beneficiary receiving home dialysis in nursing facilities, including SNFs (report along with condition code 74) |
84 |
Acute kidney injury (AKI) on a monthly basis |
86 |
Additional hemodialysis treatments with medical justification |
87 |
Self-care retraining |
H3 |
Gastrointestinal (GI) bleeding |
H4 |
Pneumonia |
H5 |
Pericarditis |
*(not all-inclusive list), when applicable
Report occurrence code 51 - Date of last Kt/V (K-dialyzer clearance of urea; t-dialysis time; V-patient’s total body water) reading
In-center hemodialysis patients.
Date of last reading taken during the billing period.
Peritoneal dialysis patients and home hemodialysis patients.
Date may be before the current billing period, but within four months of the date of service on the claim.
Report occurrence code 33 - First day of coordination period covered by employer group health plan.
Must be used in combination with value code 13 when Medicare is the secondary payer due to ESRD entitlement.
Value Code * |
Definition |
48 |
Hemoglobin reading |
49 |
Hematocrit reading |
A8 |
Weight of patient (in kilograms) |
A9 |
Height of patient (in centimeters) |
D5 |
Result of last Kt/V reading |
Revenue code * |
Definition |
0300 0634 |
Laboratory Erythropoietin (EPO), less than 10,000 units administered |
0635 |
Erythropoietin (EPO), 10,000 units or more administered |
0636 |
Darbepoetin Alfa and drugs requiring specific information |
082X |
Hemodialysis |
083X |
Peritoneal dialysis |
084X |
Continuous ambulatory peritoneal dialysis (CAPD) |
085X |
Continuous cycling peritoneal dialysis (CCPD) |
0881 |
Ultrafiltration, performed separately from dialysis treatment |
Report the appropriate HCPCS codes, when applicable.
HCPCS* |
Definition |
|
90999 |
Unlisted dialysis procedure, inpatient or outpatient |
|
J0882 J0887 |
Injection, Darbepoetin Alfa, 1mcg (for ESRD on Dialysis) (Aranesp) Injection, Epoetin Alfa, 100 units (for ESRD on Dialysis) |
|
Q4081 Q5105 |
Injection, Epoetin alfa, 100 units (for ESRD on Dialysis) Injection, Epoetin Alfa-EPBX, Biosimilar (Retacrit) (for ESRD on Dialysis) 100 units |
|
Modifiers* |
Definition |
AX |
Item furnished in conjunction with dialysis services |
AY |
Item or service furnished to an ESRD patient that is not for the treatment of ESRD |
CG |
Policy criteria applies (report with revenue codes 0821 or 0881 and HCPCS 90999 when billing dialysis treatments in excess of the 13 or 14 monthly allowable treatments) |
ED |
Hematocrit greater than 39.0% or hemoglobin greater than 13.0g/dL for 3 or more consecutive billing cycles immediately prior to and including the current billing cycle |
EE |
Hematocrit greater than 39.0% or hemoglobin greater than 13.0g/dL for less than 3 consecutive billing cycles immediately prior to and including the current billing cycle |
EJ |
Subsequent claims for a defined course of therapy, e.g., EPO, sodium hyaluronate, infliximab |
EM |
Emergency reserve supply |
ET |
Emergency services |
GS |
Dosage of EPO or Aranesp has been reduced and maintained in response to hematocrit or hemoglobin level |
G1 |
Most recent Urea Reduction Ratio (URR) of less than 60% |
G2 |
Most recent Urea Reduction Ratio (URR) of 60% to 64.9% |
G3 |
Most recent Urea Reduction Ratio (URR) of 65% to 69.9% |
G4 |
Most recent Urea Reduction Ratio (URR) of 70% to 74.9% |
G5 |
Most recent Urea Reduction Ratio (URR) of 75% or greater |
G6 |
ESRD patient for whom less than seven dialysis sessions have been provided in a month |
JA |
Administered intravenous |
JB |
Administered subcutaneous |
JW KX |
Drug amount discarded/not administered Medical policy requirements met for extra session |
Q3 |
Kidney donor services |
UJ |
Services provided at night |
V5 |
Any vascular catheter (alone or with any other vascular access) Note: ESRD claims for hemodialysis must indicate the type of vascular access used for the delivery of the hemodialysis at the last hemodialysis session of the month. A code is required to be reported on the latest line-item date of service billing for hemodialysis revenue code 0821. It may be reported on all revenue code 0821 lines at the discretion of the provider. |
V6 |
Arteriovenous graft (or other vascular access, not including a vascular catheter) Note: ESRD claims for hemodialysis must indicate the type of vascular access used for the delivery of the hemodialysis at the last hemodialysis session of the month. A code is required to be reported on the latest line-item date of service billing for hemodialysis revenue code 0821. It may be reported on all revenue code 0821 lines at the discretion of the provider. |
V7 |
Arteriovenous fistula only (in use with two needles) Note: ESRD claims for hemodialysis must indicate the type of vascular access used for the delivery of the hemodialysis at the last hemodialysis session of the month. A code is required to be reported on the latest line-item date of service billing for hemodialysis revenue code 0821. It may be reported on all revenue code 0821 lines at the discretion of the provider. |
ESRD facilities furnishing dialysis treatments in-facility are paid for up to 3 treatments per week. ESRD facilities treating patients at home regardless of modality receive payment for 3 hemodialysis (HD) equivalent treatments per week. Payment for additional treatments may be considered when there is medical justification for more than 3 weekly treatments.
Hemodialysis: Payment based on standard of three treatments per week.
Peritoneal Dialysis (CAPD and CCPD): Payment based on hemodialysis equivalent sessions.
For home patients undergoing peritoneal dialysis (PD), the number of days of PD regardless of the number of dialysate exchanges performed each day, is converted to HD-equivalent sessions. This is accomplished by dividing the number of days of PD by 7 and multiplying the result by 3.
Intermittent Peritoneal Dialysis (IPD): Payment based on hemodialysis equivalent sessions.
Hemofiltration: Alternative to peritoneal dialysis and hemodialysis. payment based on hemodialysis equivalent sessions.
* Regardless of dialysis modality or treatment setting, payments for additional treatments may be made when they are medically justified. The A/B MAC (A) reviews the medical justification and is responsible for making the decision on the appropriateness of the extra treatment.
Revenue code |
Frequency |
Condition code |
Value code |
Monthly limit |
0634-EPO<10,000 or 0635-EPO>10,000 |
Three times per week |
N/A |
48 and/or 49 |
13 times in 30 days/ 14 times in 31 days |
0636- Darbepoetin Alfa (DPO) (Aranesp) |
N/A |
N/A |
48 and/or 49 |
5 times per month |
082X- Hemodialysis |
Three times per week |
71,72,73,74,76 |
A8,A9,D5 |
13 times in 30 days/ 14 times in 31 days |
083X- Intermittent Peritoneal Dialysis (IDP) (home or outpatient) Waste is removed indirectly by instilling a special solution into the abdomen using the peritoneal membrane as a filter. |
Three times per week |
71,72,73,74,76 |
A8, A9,D5 |
HD equivalent sessions |
084X-Continuous Ambulatory Peritoneal Dialysis (CAPD) Outpatient continuous dialysis process performed outpatient or home when patient uses peritoneal membrane as a dialyzer |
HD equivalent sessions |
73 or 74 |
A8,A9,D5 |
HD equivalent sessions |
085X- Continuous Cycling Peritoneal Dialysis (CCPD) Outpatient continuous dialysis process performed outpatient or home when patient uses peritoneal membrane as a dialyzer |
HD equivalent sessions |
73 or 74 |
A8,A9,D5 |
HD equivalent sessions |
The Fiscal Intermediary Shared System (FISS) uses the “from date” instead of the line-item date of service on ESRD PPS claims to determine how to process HCPCS not paid under the ESRD PPS.
When billing a HCPCS not covered under ESRD PPS, the ESRD claim should be split based on the effective date of the change to the HCPCS.
If a HCPCS rate changes mid-month, the claim should be billed split to allow the correct rate to be applied or if the service is able to be submitted alone, i.e., COVID or flu codes, submit the service on a 72x claim by itself.
Example split claim: HCPCS rate changed on 5/19
First claim should be billed from 5/1 through 5/18.
Second claim should be billed from 5/19 through 5/31 with the HCPCS on the 5/19 - 5/31 claim.
This will allow FISS to apply the correct rate based on the 5/19 “from date.”
Example split claim: HCPCS effective date 5/3
First claim should be billed from 5/1 through 5/2.
Second claim should be billed from 5/3 through 5/31 with the HCPCS on the 5/3 - 5/31 claim.
This will prevent the service from receiving a reason code for invalid HCPCS based on the 5/3 “from date.”
Example claim with HCPCS by itself: HCPCS rate changed 5/19
The HCPCS should not be reported on the ESRD PPS claim. Bill normal ESRD PPS claim with from 5/1 through 5/31.
For the HCPCS with the rate change, submit the 72x claim with just the date of service the HCPCS was provided, for example from 5/25 through 5/25 with any appropriate additional coding that may be required for the specific HCPCS.
This will allow FISS to apply the correct rate based on the “from date.”
* Indicates not all-inclusive list, when applicable