Response to Comments: Frequency of Hemodialysis

Palmetto GBA received numerous comments related to DL34575. Palmetto GBA has an existing Local Coverage Determination (LCD) for this subject and this present draft form is a revision of the existing LCD. In this revision there is expansion of the coverage diagnoses, addition of the use of a modifier to identify those additional treatments needed, and establishment of an appropriate way for redetermination (appeals) should a denial occur for those diagnoses not in the list. As noted in the document, the draft addresses a narrow issue for the End Stage Renal Disease (ESRD) program and does not change the base payment process issued by The Centers for Medicare and Medicaid Services (CMS). CMS charged Local Contractors (Medicare Administrative Contractors [MACs]) to develop a list of clinical conditions appropriate for payment beyond the standard thrice weekly payment. This list (included in the draft) is felt to be appropriate for such payments should medical documentation be supportive. All payment policies for the ESRD program reside with CMS for other changes. MACs do not have the discretion to change any basic payment policies related to this issue and is only defining a list of clinical conditions that up front in the submission of a claim could be felt to be appropriate for additional payment should medical documentation support use, if reviewed. There may be other clinical situations that require additional treatments. These services, even though they do not have a diagnosis listed, can be noted by an appended KX modifier ( see Coding for Hemodialysis Sessions A55354 ) for more billing and coding information. Additional review following an initial denial would be available through the redetermination process. Additional review may result in the addition of diagnosis codes to the Local Coverage Determination. In the comment review period, all submitted published literature was reviewed. Palmetto GBA does not do research based on bibliographies that may have been submitted along with comments. Many of the issues submitted were similar and gathering of like-comments was done for a response. A large number of literature articles were submitted by industry that encompassed the requests from others who did not submit literature. In general, the comments address home dialysis and more frequent dialysis as a baseline for payment. This issue is outside the scope of the draft LCD and will need to be addressed to, and by, CMS. MACs do not have discretion to change payment strategies for CMS. The comments can generally be divided into three comment groups: Patient, caretakers, those who work with these patients Providers Industry