Forum - Questions & Answers

May 3rd, 2018 - anitac

CPT code for dialysis physician capitation charge

I regularly bill Mississippi payers a CPT code of 90960-90966 for my providers Monthly Capitation charge. What is the CPT code for billing the provider monthly capitation charge in the state of Arkansas? I have received denials for 90960-90966 codes from Medicare. Or, any suggestions on finding the code(s) needed would be very appreciated. Thank you, Anita Chrestensen

Jun 5th, 2018 - ChrisW   256  1 


This is really an open-ended question, what was the reason for denial? Medicare did a review of findings and stated there is a 41% claim denial rate on 90960-90961 due to the following reasons also either the provider did not respond or the information supplied did not support the service.

* Insufficient documentation to support the services billed
* No indication of face to face visits by the provider for the qualifying monthly capitation payment (MCP).
* Records signed illegibly and no signature log submitted in response to Medical Review’s call to the provider"

Here are some important guidelines from the Medicare Claims Processing Manual (Chapter 8, section 140.1) are:
• "Visits must be furnished face-to-face by a physician, clinical nurse specialist, nurse practitioner, or physician’s assistant"
• "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."
Is it “At home” services? Effective for claims with dates of service on or after April 1, 2007, line item billing is required for all dialysis sessions. For intermittent home dialysis under method one, the provider submits a separate line item for each dialysis session using the dates in the predetermined plan of care and the units reported on each line should be one. In the event that the schedule was changed, the provider should note the changes in the medical record and bill according to the revised schedule.

Was there an Inpatient stay?

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