CMS Announces New Modifier for Noncovered Hemodialysis

Posted on Posted in Medical Coding Blog

If your claim provides for excess dialysis treatment rendered to a Medicare patient, you might be interested to know that a new modifier has been created by the Centers for Medicare and Medicaid Services (CMS) to help in coding and billing for the service.

Modifier CG Policy criteria applies, is an informational modifier that indicates the facility attests the additional treatment does not meet justification requirements and should not be paid separately under the End Stage Renal Disease Prospective Payment System (ESRD PPS). Its use is limited to only Medicare and Medicaid beneficiaries.

“Modifier CG is used to identify dialysis treatments (90999 Unlisted dialysis procedure, inpatient or outpatient,) in excess of 13 or 14 per month that do not meet medical justification requirements as defined by the MACs. This modifier shall be appended to the claim line for the date of service associated with the excess treatment,” CMS policy states.

How Billing Extra HD Sessions Works

Usual billing policy indicates that you can code for extra hemodialysis sessions in a month as long as a licensed healthcare professional ascertains the service. A physician’s order is a requirement, too, to ensure that the additional sessions are medically necessary.

You would code these medically necessary extra hemodialysis sessions with CPT code 90999 and modifier KX Specific required documentation on file. This modifier is a way to signal to Medicare, “I know you have special rules for this item and I am certifying that we have met all of those requirements so please pay this claim.” These codes should be supported with documentation showing appropriate medical justification as outlines in MAC’s (Medicare administrative contractor) policy.