About 14% of people on dialysis are doing some type of home dialysis, down from about 60% before Medicare began paying for dialysis in 1973.

Many people wonder what factors have contributed to the decline in home dialysis. One study of U.S. nephrologists found that doctors who have been in practice for 11 or more years were significantly less likely to recommend PD (Thamer M, et al. U.S. nephrologists' recommendation of dialysis modality: Results of a national survey. Am J Kidney Dis. 36(6):1155-65, 2000). Those who did recommend PD were significantly more likely to refer patients who still had some residual renal function and were:

• Male (authors suggest female body image concerns or physician bias)
• Compliant
• Under 200 pounds
• Not diabetic
• Living with family

Study authors expressed the concern that if nephrologists continue to use these factors as determinants, the growing incidence of diabetes, obesity, malnutrition, patients living alone, and substance abuse could limit the future use of PD.

However, another study of practicing nephrologists found that respondents (47% of the total) believed PD and home hemodialysis were underutilized. In fact, they believed that 11-14% of patients could do home hemodialysis and 26-39% of patients could do PD. (Mendelssohn DC, et al. What do American nephologists think about dialysis modality selection? Am J Kidney Dis. 37(1):22-29, 2001.)

These physicians stated that the following are factors to consider in modality selection (in order from highest to least important):

• Patient preference
• Patient quality of life
• Morbidity
• Mortality
• Clinic reimbursement
• Physician reimbursement

There are multiple benefits for patients who do home dialysis:

• Choose a treatment that fits your lifestyle.
• Get Medicare right away. This may help patients get coverage for PD or HD access placement if surgery is scheduled early in the month that dialysis starts, and training starts before the first day of the third full month of dialysis.
• Schedule your dialysis treatment around work and other responsibilities vs. having the clinic schedule your dialysis to fit its needs.
• Be in more control of your treatment, with better understanding of the dialysis process.
• Travel to a clinic only once or twice a month compared with 13-14 times.
• Reduce your risk of infection due to exposure to other patients and staff.
• Do dialysis in the comfort of your home where you can eat and drink when you want to, have friends and family over, watch your favorite TV shows, or listen to music without earphones, pay bills, make phone calls, work on your computer, talk and play games with your family, etc.
• Only one or two people will use your hemodialysis access so you have fewer chances of access problems.

There are many benefits to clinics when patients choose to do home dialysis:

• Patients can get Medicare coverage from the first of the month dialysis starts, instead of having to wait until the first day of the third full month of dialysis. (Even if a patient tries and fails home dialysis training, Medicare will backdate the effective date to the first of the month dialysis starts.)
• Each home dialysis staff person can support 20 or more patients, reducing the need to hire and train more staff to keep up with the growing patient population.
• Having a larger percentage of home patients reduces the need to expand or build more clinics.
• Offering home dialysis allows more patients to keep their jobs and their Employer Group Healthcare Plan (EGHP) coverage as their primary payer for 30 months, and as a secondary payer afterward.
• Offering home dialysis allows the clinic to offer patients that desire to be in more control (often the ones staff have conflicts with) the option to learn more and do dialysis at home.

Home dialysis patients have outcomes as good as, or better than, in-center hemodialysis patients. In addition, physicians are paid $500 (subject to the deductible and coinsurance) when a patient completes home dialysis training, to cover such services as:

• Directing and participating in training
• Reviewing the family and home status, environment, and counseling and training family members
• Reviewing training materials

If a patient does not complete training, this physician fee is prorated at $20 per training session for all types of home training.

Physicians can also be paid $20 per re-training session up to $500 if there is a change in the type of dialysis the patient does or the equipment the patient uses.

For physician reimbursement for training and retraining, see Chapter 8, §150 of the Medicare Claims Processing Manual.

Most health insurance pays for home dialysis and training. If a patient's insurance won't approve home dialysis or training, the doctor, dialysis clinic, or ESRD Network may be able to advocate on the patient's behalf. Once the insurance company knows that people who choose home dialysis do as well or better than those on in-center dialysis, and that home dialysis may be cheaper, it will probably cover these services.

Besides private insurance, Medicare, Medicaid (state medical assistance for people with low incomes), Veterans Administration, Indian Health Service, and some state kidney programs will help pay for dialysis, too. The dialysis billing staff or social worker can explain coverage for dialysis.

It is essential that dialysis clinics verify and advocate for EGHPs to pay for home dialysis training, equipment, supplies, and follow-up support services. When the patient has an EGHP, the EGHP is primary for 30 months regardless of whether dialysis is done in-center or at home.

Primary coverage does not switch from an EGHP to Medicare just because a patient signs up for Medicare. The clock starts ticking from the date that the patient could have taken Medicare—whether he/she did or not. An EGHP may refuse to pay primary benefits after this date.

Patients and clinics should know whether the patient's health insurance has a lifetime benefit limit or a limit for kidney-related services. Depending on the patient's situation, hospital bills and clinic fees for dialysis can exhaust a patient's EGHP benefits, leaving the patient without coverage for medications or other healthcare needs. Having part of these costs paid by Medicare can help prevent the exhaustion of EGHP coverage.

There are a number of benefits to clinics if patients keep their EGHP coverage including:

• Commercial payers typically pay more for services than Medicare does. This allows clinics to provide better equipment and more innovative treatments and services than they could provide if all patients had Medicare as their primary payer.
• The Medicare composite rate requires that clinics bill a set amount for a certain bundle of services. A clinic can bill the EGHP for all services provided on all dates of service, and the EGHP will determine the amount it will pay.
• Medicare does not cover everything that EGHP plans cover. For instance, an EGHP may cover more dialysis treatments than Medicare covers. (This can be important for daily or nocturnal hemodialysis programs.) Do not assume that an EGHP has the same limits that Medicare imposes.
• There are still many questions about how the new Medicare Part D plan (prescription drug coverage that starts in 2006) will pay for drugs Medicare has been covering. Currently, Medicare allows a clinic to bill separately for a limited number of drugs at home like EPO (Epogen® or Aranesp®). Medicare does not pay separately for antibiotics for home patients used for peritonitis or catheter infections. Whether or not Medicare Part D will pay for drugs provided by a clinic to its home patients, these patients will find that even though they will have coverage for drugs they take at home, there will be gaps during which they will have to pay 100% for their drugs. In fact, if a patient takes drugs costing $5,100 a year, the patient will still owe $3,600 for these drugs.

Patients need to know when considering whether to sign up for Medicare:

• Having Medicare protects a patient's rights to get COBRA if any event occurs that requires a company to offer it.
• Having Medicare protects the patient's rights to coverage for immunosuppressant medications after a transplant. If the patient doesn't have or sign up for Medicare to start the month of the transplant, he or she will never have Medicare coverage for these drugs, under current Medicare rules.
• If a patient signs up for Medicare Part A and waives Part B due to good EGHP coverage, the Part B premium will be higher once the patient signs up, and there could be a coverage gap. After the initial enrollment period, people can only sign up for Medicare during the general enrollment period each year (January through March). The only ways to avoid the premium penalty and limited enrollment are to:
  • Waive both Part A and Part B when first offered Medicare;
  • Disenroll from Medicare A and repay Medicare any claims it has paid.
• The clinic can bill Medicare for deductibles and coinsurance and for items and services Medicare covers that the EGHP doesn't; e.g., transient dialysis when a patient travels outside an HMO's service area.
• Having Medicare limits the amount any Medicare provider can charge someone. As a primary payer, a provider can bill the EGHP its commercial rate, which is often more than Medicare allows. If the EGHP does not pay its allowed charge in full, the clinic can bill Medicare as a secondary payer for deductibles and coinsurance. If the EGHP pays at least as much as Medicare allows, the provider cannot bill the patient the difference between its charge and the EGHP allowable.

For information about submitting Medicare Secondary Payer claims, see Chapter 3, §30 of the Medicare Secondary Payer Manual.

According to 42CFR405 Subpart U, the Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services, a home dialysis training program must have a nurse who meets the following qualifications:

1. At least 12 months of experience in clinical nursing, and an additional 6 months of experience in nursing care of the patient with permanent kidney failure or undergoing kidney transplantation, including training in and experience with the dialysis process; or
2. 18 months of experience in nursing care of the patient on maintenance dialysis, or in nursing care of the patient with a kidney transplant, including training in and experience with the dialysis process;
3. At least 3 months of the total required ESRD experience is in training patients in self-care, if the nurse responsible for nursing service is in charge of self-care dialysis training. [42CFR405.2102(d)]

• Download the ESRD regulations

A dialysis clinic can use its own staff to provide home dialysis services or can contract with individuals to provide the training and support services.

In addition to other responsibilities, the physician director must take part in the selection of an appropriate treatment for patients and must assure that patient teaching materials are available for use by self-care or home dialysis patients during training and at times other than when they are on dialysis. [42 CFR 405.2161]

When a patient does home dialysis and has Medicare, he/she must choose how to get supplies and equipment and who is going to bill Medicare—the clinic, or the supply company. Patients make this choice on the CMS-382 (ESRD Beneficiary Selection) form. A patient has one chance each year to change from one Method to the other. Changes take effect the following January 1. If the patient is not covered by Medicare, he/she does not need to make a Method selection.

When a patient chooses Method I, the dialysis clinic installs and maintains the machine (if one is needed), provides supplies, and supports the patient through regular clinic visits, phone calls, and sometimes home visits. The clinic charges the Medicare approved amount (composite rate) for these services. Medicare pays 80% of the approved charge. Since dialysis clinics accept Medicare assignment, your clinic cannot bill the patient or his/her insurance more than the 20% balance that's left. Your administrator or billing personnel can tell you your clinic's composite rate which varies by type of clinic (hospital or freestanding) and your location. Effective April 1, 2005, the composite rate will be adjusted according to certain patient factors.

When a patient chooses Method II, the dialysis clinic only bills for support services-visits with the nurse, social worker, and dietitian at the clinic or in the patient's home. The clinic helps the patient get his/her machine (if needed) and supplies directly from a supply company. The supply company installs and maintains the machine, delivers the supplies, and bills Medicare. Medicare allows supply companies to charge more under Method II for machines and supplies than clinics can charge under Method I. In fact, under Method II, supply companies can charge $1,974.45 for APD (CCPD) and $1,490.85 for CAPD and HHD. The dialysis clinic can charge $121.15 for support services and $15 if the staff needs to change a PD connecting tube. Medicare pays 80% of the higher amount it lets a supply company charge, plus 80% of the amount the dialysis clinic can charge for support services. Because these charges are higher, the 20% the patient or his/her insurance will owe could be higher if the patient chooses Method II.

When a patient selects Method I, Medicare will cover reasonable and necessary expenses that the clinic incurs to install home dialysis equipment to do home hemodialysis or APD, including:

• Delivery to the home of home dialysis equipment needed to do APD or HD.
• A system to purify water for HD.
• Plumbing and/or electrical work to tie the equipment into existing plumbing and electrical systems. Medicare will not pay to wire the room where the APD or HD machine is located or install plumbing to the room.
• Testing the APD or HD equipment to be sure it is working correctly. Medicare will not pay for equipment maintenance contracts, but will pay for maintenance as it is provided.
• A basic recliner chair (for HD) that does not rock, swivel, vibrate, or heat. If the patient wants to have a recliner with these features, the invoice should indicate the charge for the basic chair. The patient can pay to upgrade to premium features.
• A meter to measure the conductivity of HD dialysis solution.
• Supplies to test blood, including a meter to measure hemoglobin and a centrifuge.
• Scale, thermometer, scissors, clamps, etc., if provided at no extra charge with the home dialysis equipment.

When a Method I patient does home dialysis, the clinic must provide all supplies and equipment the patient needs under its composite rate. This includes such things as alcohol wipes, gloves, sterile drapes, 4x4s and bandages, dialyzers and tubing for HD, dialysate, heparin, xylocaine, and antibiotics used to treat PD catheter infections and peritonitis, plus support services. (If a Method I patient needs an antibiotic to treat something other than a catheter infection or peritonitis, the dialysis clinic can bill separately for the antibiotic.) As a primary payer, Medicare pays 80% of this amount, less the deduction that pays for ESRD Networks. As a secondary payer, Medicare can be billed for an EGHP's deductibles and coinsurance. Medicare can be billed as a primary payer with documentation of an EGHP's denial of coverage.

The Medicare Claims Processing manual that addresses home dialysis states this:

The following items are paid for and must be furnished under the composite rate. The facility may furnish them directly under arrangements, to all of its home dialysis patients. If the facility fails to furnish (either directly or under arrangements) any part of the items and services covered under the rate, then the facility cannot be paid any amount for the part of the items and services that the facility does furnish.

• Medically necessary dialysis equipment and dialysis support equipment;
• Home dialysis support services including the delivery, installation, maintenance, repair, and testing of home dialysis equipment, and home support equipment;
• Purchase and delivery of all necessary dialysis supplies;
• Routine ESRD related laboratory tests; and
• All dialysis services furnished by the facility's staff.

See Section 80.1 of the Medicare Claims Processing Manual, Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims.

When a patient selects Method II, the clinic must have an agreement with the supplier that provides all the home HD and PD equipment and supplies the patient needs to do home dialysis. (A supplier cannot be a Medicare approved dialysis facility.)

The dialysis clinic must provide home training and the following support services for patients on any home treatment, and can bill Medicare for the following:

• Surveillance of the patient's home adaptation, including provision for visits to the home or clinic
• Consultation with the qualified dietitian and qualified social worker
• A record keeping system that assures continuity of care
• Installation and maintenance of equipment
• Testing and appropriate treatment of water
• Ordering of supplies on an ongoing basis

In addition, a clinic must provide the following for PD patients:

• Change the connecting tube (also referred to as an "administration set").
• Watch the patient perform CAPD and assure that it is done correctly. This includes reviewing the patient's technique for anything he/she may have forgotten and training the patient how to use a new apparatus or technique.
• Document if the patient has or has had peritonitis that requires physician intervention or hospitalization (there is no need for a culture if there is no evidence of peritonitis).
• Inspect the PD catheter exit site.

Medicare will pay for home dialysis equipment (PD or HD) that a patient is not using for up to 3 months if the patient is:

• Temporarily unable to do home dialysis because of a health problem
• Temporarily without a home dialysis partner
• Temporarily away from home but intends to return there
• Temporarily doing in-center dialysis while awaiting an expected transplant

See Chapter 11, §50.2 of the Medicare Benefit Policy Manual.

Yes. Whether the patient or a partner, paid or unpaid, takes primary responsibility for treatment, the treatment itself is considered home (or self-care) dialysis.

If a patient resides in a skilled nursing facility (SNF) and gets dialysis there, the SNF can be considered the patient's home for home dialysis purposes. Dialysis charges are paid in addition to the consolidated payment that SNFs receive. As usual, dialysis clinics bill Medicare for Method I patients and suppliers bill Medicare for Method II patients.

No. Medicare does not cover the services of home dialysis helpers and clinics cannot report expenses they pay for home dialysis helpers on their cost report form.

A patient who pays a helper may want to talk with his or her tax advisor about deducting this expense as a medical deduction.

If a patient who gets disability checks hires a home dialysis helper so he or she can work, he or she can show Social Security how much was paid to this person the month work earnings were received. Social Security can consider this expense an impairment-related work expense and deduct it from the patient's earnings. So, the patient can still get disability checks while also benefiting from working, including the possibility of having EGHP coverage.

Medicare allows the clinic to charge its usual hemodialysis composite rate plus:

• $12 for each CAPD training day
• $20 for each CCPD training day

As a primary payer, Medicare pays 80% of this amount, less the $1.50 deduction per week to pay for ESRD Networks.

Medicare routinely pays for up to 15 training days for CAPD or CCPD. The Medicare payment is for staff time, supplies, routine labs, and training materials. If most patients take longer to train, it may be in the clinic's best interest to apply for an exception.

Medicare will pay for re-training at the same rate if the patient changes treatment type, gets new equipment, changes to a different setting, has a new helper, or his/her condition changes (physical limitations, memory problems, etc.).

See Chapter 8, §50.8 of the Medicare Claims Processing Manual.

Medicare allows the clinic to charge its usual composite rate plus $20 for each home hemodialysis training session. As a primary payer, Medicare pays 80% of this amount less 50 cents per treatment to pay for ESRD Network services.

Most patients are trained in 2 months. Medicare routinely allows 25 home hemodialysis training sessions. Home hemodialysis training sessions usually last 5 hours, and clinics may train 3 or 4 days a week. Medicare recognizes that some patients are trained to do the entire treatment themselves, and in other cases a home dialysis partner is trained to take primary responsibility.

Medicare will pay $20 plus the clinic's composite rate for re-training at the same rate if the patient changes treatment type, gets new equipment, changes to a different setting, has a new helper, or his/her condition changes (physical limitations, memory problems, etc.).

A dialysis clinic bills the Medicare Intermediary for dialysis. The Medicare Intermediary pays for PD based on a week of hemodialysis at 80% of the allowed rate less $1.50 per week to pay for ESRD Network services. Therefore, Medicare pays the same amount for a week of PD treatment as it pays under the composite rate for a week of hemodialysis treatments, no matter how many days or PD exchanges the patient does. See Chapter 8, §80.4 of the Medicare Claims Processing Manual.

Dialysis clinics can charge Medicare the same composite rate for home hemodialysis treatments as they charge for in-center hemodialysis even though the labor costs are lower. Medicare will pay 80% of the composite rate less 50 cents per treatment that goes to pay for ESRD Network services.

Clinics must bill the Medicare Intermediary on the UB092 (CMS-1450) claim form for home hemodialysis treatments using the following code:

• 0821 Hemodialysis/Composite or other rate - HEMO/COMPOSITE

If a patient chooses Method II, the supply company must bill the Medicare durable medical equipment regional carrier (DMERC) for PD equipment and supplies. The supply company must accept Medicare assignment. The maximum that a supplier can bill for one month is:

• $1,974.45 for APD (CCPD)
• $1,490.85 for CAPD

See Chapter 8, §90.2.2 of the Medicare Claims Processing Manual.

The supplier must have an agreement with a dialysis clinic or other provider to give antibiotics when needed. Under Method II, antibiotics for pertonitis or a catheter infection are included in the cap a supplier can charge.

See Chapter 8, §90.5 of the Medicare Claims Processing Manual.

Suppliers bill the DMERC on the CMS-1500 claim form using the following codes:

• 0832 Peritoneal Dialysis - Home Supplies (this is for little-used Intermittent PD)
• 0833 Peritoneal Dialysis - Home Equipment (this is for little-used IPD)
• 0842 CAPD - Home Supplies
• 0852 CCPD - Home Supplies
• 0853 CCPD - Home Equipment

See Chapter 8, §90.5.1.1 of the Medicare Claims Processing Manual.

The supplier must bill its durable medical equipment regional carrier (DMERC) for home dialysis equipment and supplies. The supply company must accept Medicare assignment. The maximum a supplier can bill for home hemodialysis equipment and supplies for one month is $1,490.85.

See Chapter 8, §90.2.2 of the Medicare Claims Processing Manual.

Suppliers bill the DMERC on the CMS-1500 claim form using the following codes:

• 0822 Hemodialysis - Home Supplies
• 0823 Hemodialysis - Home Equipment

In addition to those things that a clinic must provide to any patient on any home treatment, clinics that offer PD must also:

• Change the connecting tube (also referred to as an "administration set").
• Watch the patient perform PD and assure that it is done correctly. This includes reviewing the patient's technique for anything he/she may have forgotten and training the patient how to use a new apparatus or technique.
• Document if the patient has or has had peritonitis that requires physician intervention or hospitalization (there is no need for a culture if there is no evidence of peritonitis.
• Inspect the PD catheter exit site.

Support services are paid on a reasonable charge basis to independent facilities and a reasonable cost basis to hospital-based facilities. A reasonable cost determination must be made for each individual support service furnished to PD patients.

Medicare allows dialysis clinics to charge $121.15 for support services to a PD patient. Lab services and supplies are not included. When it is necessary to change the connecting tube, the dialysis clinic can charge up to $15 for supplies and the staff time required. Under an agreement between the supplier and the dialysis clinic, the clinic will provide antibiotics to patients when needed. When the patient needs an antibiotic for peritonitis or a catheter infection, the supplier is responsible for these charges and the clinic can charge the supplier. If the antibiotic is needed for any other condition, the dialysis clinic can charge Medicare.

See Chapter 8, §90.5 of the Medicare Claims Processing Manual.

Clinics must use these codes on a UB-92 (CMS-1450) claim form to bill the Medicare Intermediary for support services:

• 0845 - Continuous Ambulatory Peritoneal Dialysis (CAPD) - Support Services - CAPD/HOME/SUPSERV
• 0855 - Continuous Cycling Peritoneal Dialysis (CCPD) - Support Services - CCPD/HOME/SUPSERV

See Chapter 8, §90.5 of the Medicare Claims Processing Manual.

Support services are paid on a reasonable charge basis to independent facilities and a reasonable cost basis to hospital-based facilities. A reasonable cost determination must be made for each individual support service furnished to home patients.

Medicare allows a clinic to charge $121.15 for support services. Lab services and supplies are not included.

Clinics must use this code on a UB-92 (CMS-1450) claim form to bill the Medicare Intermediary for support services to home hemodialysis patients:

• 0825 - Hemodialysis - Support Services - HEMO/HOME/SUPSERV

These are the codes to use to bill for home dialysis patients that the nephrologist supervises for the full month based on the age of the patient:

• < 2 years old - G0320
• 2-11 years old - G0321
• 12-19 years old - G0322
• 20 or older - G0323

Physicians are to bill for 1 unit of service for supervision of a home dialysis patient who does home dialysis the whole month. Medicare reimbursement is the same as what it would be for seeing an in-center patient 2-3 visits. CMS recommends that the physician see the home patient monthly, but doesn't currently require it.

If the patient is not a home patient for the whole month because he or she is hospitalized or treated by another doctor, use the codes G0324-G0327 (below) and bill for the number of days. Payment per day is at 1/30th of the monthly rate.

• < 2 years old - G0324
• 2-11 years old - G0325
• 12-19 years old - G0326
• 20 or older - G0327

These are the codes to use for home training:

• Patient completed training - use 90989 with the description "Dialysis training, patient, including helper where applicable, any mode, completed course." The MD bills $500 and Medicare reimburses at 80% after deductible.
• Training started but not completed - use 90993 with the description "Dialysis training, patient, including helper where applicable, any mode, course not completed, per training session." The MD can bill at $20 per training session (based on 25 training sessions at $20/session for $500 total). Medicare reimburses at 80% after deductible.
• Retraining - use 90993 if a home patient later requires training for a different machine, a different dialysis modality, a change in setting, or a change in dialysis partner. The MD can bill at $20 per training session. Medicare reimburses at 80% after deductible.

If you have further questions about billing for home dialysis, your Medicare carrier would be a good resource.