Documentation Requirements for Treatment of End Stage Renal Disease

Description

This policy describes the documentation that providers must submit (or have previously submitted) in order to be reimbursed for dialysis and transplant services supplied for the purpose of treating End Stage Renal Disease (ESRD).

Kidney disease affects thousands of Americans each year. Although preventive treatments and early disease recognition have improved clinical outcomes for many patients, a significant percentage of this population will require dialysis and/or kidney transplantation. When an individual develops ESRD and either begins a regular course of dialysis treatment or receives a kidney transplant, the Centers for Medicare and Medicaid Services (CMS) requires the completion and submission of a CMS form 2728.¹ this document provides medical evidence of ESRD and important information regarding Medicare eligibility and entitlement. The information on this form is highly confidential and is important in aiding caregivers and assuring quality for ESRD patients.

Receipt of CMS form 2728 provides Blue Cross Blue Shield North Carolina (BCBSNC) information necessary to assist affected members with their ESRD care and benefits coordination, as well as to provide individual health coaching, education, decision support, and assistance with their transition to Medicare.

¹ https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS2728.pdf

***Note: This Reimbursement Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) requires a CMS form 2728 for every member who undergoes a regular course of dialysis or receives a kidney transplant for the purpose of treating ESRD. Blue Cross NC requires providers of ESRD-related dialysis and transplant services to ensure that a CMS form 2728 is on file with Blue Cross NC for a member no later than sixty (60) days after an ESRD-related dialysis or transplant claim is submitted for reimbursement of dialysis or transplant services supplied to that member.

Reimbursement Guidelines

Providers who perform dialysis or kidney transplants for the purpose of treating ESRD must submit (or have previously submitted) a CMS form 2728 to Blue Cross NC no later than sixty (60) days after a dialysis or transplant claim is filed for that specific claim to be reimbursable. The CMS 2728 form may be submitted by fax utilizing the following number: 919-287-5411.

The CMS form 2728 must also be maintained by the provider as part of the member’s healthcare documentation and updated as necessary.

Providers are not required to submit CMS form 2728 for any patients who are diagnosed with or treated for acute renal injury, and should only submit this form for patients receiving treatment for chronic ESRD.

Rationale

According to the CMS website, the CMS form 2728 is required by law to be completed on patients in the following categories:

Initial

• For all patients who receive a kidney transplant without a course of dialysis
• For patients for whom a regular course of dialysis has been prescribed by a physician

Re-entitlement

• For patients who return to dialysis three years following a transplant and ESRD Medicare benefits were terminated
• For patients who return to dialysis after stopping dialysis for more than 12 months and their benefits were terminated

Supplemental

• For patients who receive a transplant within the first three months of the date of first dialysis (to be completed by the transplant facility)
• For patients who train for self-care dialysis within the first three months of the date of first dialysis

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at Blue Cross NC.

The following ICD-10 diagnosis codes are applicable for chronic ESRD: N18.1, N18.2, N18.3, N18.4, N18.5, N18.6, N18.9, N19

The following ICD-10 diagnosis codes are specific to acute kidney failure and are not applicable to this policy: N17.0, N17.1, N17.2, N17.8, N17.9, N17.8

Related policy

Hemodialysis Treatment for ESRD (Medical Policy)

Renal (Kidney) Transplantation (Medical Policy)

Intradialytic Parenteral Nutrition (Medical Policy)

References

American Association of Kidney Patients (AAKP). https://www.aakp.org/

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual, Chapter 11, End Stage Renal Disease (ESRD); Medicare Benefit Policy Manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c11.pdf

United States Renal Data System (USRDS). https://www.usrds.org/

History

10/30/15 New payment policy regarding reimbursement guidelines for services for members with end stage renal disease. BCBSNC requires a CMS form 2728 for every member who undergoes a regular course of dialysis or receives a kidney transplant for the purpose of treating ESRD. BCBSNC requires providers of ESRD-related dialysis and transplant services to ensure that a CMS form 2728 is on file with BCBSNC for a member no later than sixty (60) days after an ESRD-related dialysis or transplant claim is submitted for reimbursement of dialysis or transplant services supplied to that member. Notification given 10/30/15 for effective date 12/30/15. (adn)

12/30/16 Routine review. Added cross reference to medical policy Hemodialysis Treatment for ESRD. (an)

12/29/17 Removed ICD-9 codes from Billing/Coding section. Routine annual policy review, no change to policy statement. (an)

2/23/18 Corrected dates in header. No change to policy. (an)

12/14/18 Routine annual policy review. No change to current policy. (an)

1/14/20 Routine policy review. Senior medical director approved 12/2019. No changes to policy statement. (an)

2/25/20 Corrected review dates in header. (an)

12/31/20 Routine policy review. Medical director approved 12/2020. No changes to policy statement. (eel)

4/20/21 Policy format update. No changes to policy statement.  (eel)  

12/30/21 Routine policy review. Medical Director approved. (eel)

12/31/2022 Routine policy review. Minor revisions only. (ckb)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.