Under the outpatient prospective payment system (OPPS) Medicare normally does not allow payment for routine dialysis treatments furnished to end stage renal disease (ESRD) patients in the outpatient department of a hospital that does not have a certified dialysis facility. The OPPS rule for 2003 allows payment for non-routine dialysis treatments furnished in the outpatient department of a non-certified hospital dialysis facility, when the patient cannot obtain his or her regularly scheduled dialysis treatment at a certified ESRD facility.
Payment for patients receiving unscheduled ESRD dialysis is limited to the following circumstances:
- Dialysis performed following, or in connection with, a vascular access procedure
- Dialysis performed following treatment for an unrelated medical emergency; e.g., if a patient goes to the emergency room for chest pains and misses a regularly scheduled dialysis treatment that cannot be rescheduled, Medicare will allow the hospital to provide and bill Medicare for the dialysis treatment
- Emergency dialysis for ESRD patients who would otherwise have to be admitted as inpatients in order for the hospital to receive payment.
A new Healthcare Common Procedure Coding System (HCPCS) code was created for non-ESRD certified hospital outpatient facilities to bill Medicare for dialysis treatments furnished to ESRD patients.
- G0257—Unscheduled or emergency treatment for dialysis for ESRD patient in the outpatient department of a hospital that does not have a certified ESRD facility. This new code is assigned to APC 0170, with status indicator (SI) “S”.
Hospitals should not report code G0257 when dialysis treatment is provided to patients with acute renal failure.
An end stage renal disease (ESRD) patient was on his way to a dialysis center for a regularly scheduled dialysis. The patient experienced substernal chest pain and stopped at the Community Hospital emergency department for care. After the patient was stabilized the decision was made to perform the dialysis treatment at the hospital, which is not certified as a dialysis center rather than have the patient make the trip to his regular dialysis center. What codes would be assigned for the dialysis treatment?
Although, your hospital is not a certified dialysis facility, under the 2003 OPPS rule payment is allowed for non-routine renal dialysis treatments provided to patients in a non-certified outpatient hospital facility. Report code G0257, Unscheduled or emergency treatment for dialysis for ESRD patient in the outpatient department of a hospital that does not have a certified ESRD facility, for the dialysis treatment provided.