Recently, the Centers for Medicare and Medicaid Services (CMS) announced that they would be changing some of their coverage guidelines in regards to dialysis. Starting on January 1st, 2018, CMS will officially begin covering outpatient dialysis for skilled nursing facility patients who are suffering from acute kidney injury, more commonly known as AKI or acute kidney failure.
Despite this move, the CMS relationship with dialysis patients hasn’t always been a strong one. For years, there was little to no Medicare coverage for AKI dialysis, despite the company covering the same procedures for end-stage renal disease (ESRD) patients. In fact, it wasn’t until the beginning of 2017 that CMS created HCPCS code G0491 and began covering AKI dialysis at all. Despite this improvement, patients receiving treatment in skilled nursing facilities were still left out until now.
Because of complex consolidated billing laws, patients with AKI were handled differently than those with ESRD. In short, ESRD requires a provider to testify that a patient’s renal function is irreversibly damaged in order to for the dialysis to be billed on its own instead of as a consolidated package. But because AKI patients may or may not recover and no longer need dialysis, the cost of their dialysis cannot be excluded from the bundle and therefore falls to the skilled nursing facility. As expected, this made these types of facilities hesitant to accept such patients, as they knew it could bring a significant financial burden.
Thankfully, code G0491 will now be used to mark each session of dialysis for reimbursement in skilled nursing facilities as well. If you are a coder for a skilled nursing facility, prepare to see an influx of these AKI patients, and be sure to pick up a copy of the HCPCS Level II 2018 updates textbook in order to keep up to date with all of the coming year’s changes.