New Medicare Part B Services for 2010: Kidney disease education

In the OPPS final rule, it was announced that there would be two new services covered under Medicare Part B – Pulmonary Rehabilitation Services and Kidney Disease Education. This week, we will take a look at the latter and the specific requirements for coverage and billing of this new service.

Effective for dates of service on or after January 1, 2010, Medicare Part B will cover the Kidney Disease Education (KDE) benefit for those beneficiaries diagnosed with Stage IV chronic kidney disease (ICD-9 diagnosis code 585.4) and have a documented referral for the service from the physician managing their kidney condition.  Chronic kidney disease (CKD) is defined as kidney damage that has existed for at least three months and may evolve over a long period of time. When CKD progresses, it may lead to kidney failure requiring dialysis or a kidney transplant. The KDE benefit is designed to help patients understand their disease process, participate in treatment decisions and possibly help delay the need for dialysis.

To be a covered benefit, the service must be furnished by a “qualified person”, meaning a physician, physician assistant, nurse practitioner or clinical nurse specialist. In addition, a hospital or critical access hospital (CAH) located in a rural area based on their actual geographic location or a hospital that has been “reclassified” from urban to rural under statute may also provide this service. However, to be considered a covered benefit, it cannot be provided by a renal dialysis facility or a provider located outside of a rural area.

Of special note is that the “incident to” requirements that hospitals must meet to qualify for other covered outpatient service will not apply to KDE services.  Also, a KDE services cannot be billed by both the facility and the professional providing the service.  Only one claim per date of service can be considered for payment. The facility and the qualified person providing the service should determine in advance who will be billing for the service.

Part B will cover up to six KDE sessions in a lifetime for beneficiaries who meet the diagnosis and referral requirements. The services should be reported with HCPCS G0420 (face-to-face education services related to the care of chronic kidney disease; individual, per session, per one hour) and G0421 (face-to-face education services related to the care of chronic kidney disease; group, per session, per one hour) and will be paid under the Medicare Physician Fee Schedule. Each session is one hour in length and there must be at least 31 documented minutes of time in order to bill one of the G-codes. The sessions must include documentation to support:

• Management of comorbidities;
• Prevention of uremic complications;
• Therapeutic options; and
• Outcomes assessments.

More information on billing, coverage, and payment of KDE services can be found in Transmittal R117BP and Transmittal R1876CP.

Next week we will take a look at the other new benefit – Pulmonary Rehabilitation Services.