23-482 Bill Correctly to Get Paid for Dialysis Treatments
Date: 06/07/23
New payment edit requires billing with hemodialysis modifier
Effective August 10, 2023, Health Net will implement a new edit described below on claim payments to ensure compliance with company standards and national billing guidelines.
Claims edit
- Hemodialysis modifier – Health Net will deny payments on claims billed for hemodialysis (CPT 90999) when a modifier (G1-G6) is not present on the claim. Per the Centers for Medicare & Medicaid Services (CMS) billing guidelines, a G1-G6 modifier is required when billing with CPT code 90999.
- Claims impacted – Bill type starting with 72X for kidney dialysis services and revenue code 082X (hemodialysis – outpatient or home) will be denied when CPT code 90999 is billed without the correct modifier.
Billing requirements
Claims for dialysis treatments must include the adequacy of dialysis dated measured by Urea Reduction Ratio (URR). Dialysis facilities must monitor monthly the adequacy of dialysis treatments for facility patients.
The appropriate modifier must be reported when using CPT code 90999 (unlisted dialysis procedure).
Modifier | Description |
|
|---|---|---|
G1 | Most recent URR of less than 60% | |
G2 | Most recent URR of 60% to 64.9% | |
G3 | Most recent URR of 65% to 69.9% | |
G4 | Most recent URR of 70% to 74.9% | |
G5 | Most recent URR of 75% or greater | |
G6 | ESRD patient for whom less than seven (7) dialysis sessions have been provided in a month | |
Additional information
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by phone or through the Health Net provider portal.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.