Monthly capitation payment for physician services furnished to beneficiaries

First Coast Service Options Inc. (First Coast) recently1 identified the billing of both the monthly capitation payment (MCP) and the daily per diem payment physician service. Providers are reminded that the below guidelines are to be applied when billing monthly and daily physician services. Physicians and practitioners managing center based patients on dialysis are paid a monthly rate for most outpatient dialysis-related physician services furnished to a Medicare end-stage renal disease (ESRD) beneficiary. The payment amount varies based on the number of visits provided within each month and the age of the ESRD beneficiary. Under this methodology, separate codes are billed for providing one visit per month, two to three visits per month and four or more visits per month. The lowest payment amount applies when a physician provides one visit per month; a higher payment is provided for two to three visits per month. To receive the highest payment amount, a physician or practitioner would have to provide at least four ESRD-related visits per month. The MCP is reported once per month for services performed in an outpatient setting that are related to the patients’ ESRD. The physician or practitioner who provides the complete assessment, establishes the patient’s plan of care, and provides the ongoing management is the physician or practitioner who submits the bill for the monthly service. Visits must be furnished face-to-face by a physician, clinical nurse specialist, nurse practitioner, or physician’s

The MCP physician or practitioner may use other physicians or qualified non-physician practitioners to provide some of the visits during the month. The MCP physician or practitioner does not have to be present when these other physicians or practitioners provide visits. In this instance, the rules are consistent with the requirements for hospital split/shared evaluation and management visits. The non-MCP physician or practitioner must be a partner, an employee of the same group practice, or an employee of the MCP physician or practitioner. For example, the physician or practitioner furnishing visits under the MCP may be either a W-2 employee or 1099 independent contractor. When another physician is used to furnish some of the visits during the month, the physician  the patient’s plan of care, and provides the ongoing management should bill for the MCP service. If the nonphysician practitioner is the practitioner who performs the complete assessment and establishes the plan of care, then the MCP service should be billed under the PIN of the clinical nurse specialist, nurse practitioner, or physician assistant.

Physicians and practitioners may receive payment for managing patients on dialysis for less than a full month of care in specific circumstances. Per diem ESRD services
should be coded using the ESRD related services (less than full moth), per day health care procedure system (HCPCS) codes for ESRD-related services in the situations described below:

*** Home dialysis patients (less than full month);

*** Transient patients – patients traveling away from home (less than full month);

*** Partial month where there are one or more face-toface visits without a complete assessment of the patient and the patient was either hospitalized before a complete assessment was furnished, dialysis stopped due to death, or the patient had a transplant.

*** Patients who have a permanent change in their MCP physician during the month.

The ESRD-related services (less than full month), per day HCPCS codes should only be used for the circumstances described above. The per diem codes may not be used for a full month when a complete monthly assessment is not furnished.