84295: Serum sodium — update to previous billing instructions 82435: Chloride; blood

An article published in the January 2010 Medicare B Update (page 51) of the publication may have led providers to a misunderstanding regarding the correct use of modifier CB (Service ordered by a renal dialysis facility [RDF] physician as part of the ESRD (end-stage renal disease) beneficiary’s dialysis benefit, is not part of the composite rate, and is separately reimbursable). The purpose of the article was to advise providers that a correction had been made regarding incorrect denials of CPT code 84295 (Sodium, serum, plasma or whole blood), when billed with the appropriate modifier to indicate that the services are outside of the ESRD composite rate. The article instructed providers to append at least modifier CB to the line item for CPT code 84295 in order to prevent the test from denying as part of the composite rate payment.

Modifier CB is a valid modifier and used for ESRD purposes. It does not, however, prevent a test from denying as being included in the ESRD composite rate. There are three modifiers (CD – AMCC [automated multi-channel chemistry] test has been ordered by an ESRD facility or MCP [monthly capitation payment] physician that is part of the composite rate and is not separately billable, CE – AMCC test has been ordered by an ESRD facility or MCP physician that is a composite rate test but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity, and CF – AMCC test has been ordered by an ESRD facility or MCP physician that is not part of the composite rate and is separately billable) used to identify the various payment situations for ESRD AAMC tests. Modifier CF is used on AMCC tests to indicate that services are ordered by an ESRD facility or MCP physician, and are not part of the composite rate.

Modifier CB is used on claims for diagnostic services related to the dialysis treatment for ESRD beneficiaries in a skilled nursing facility Part A stay. It is used to prevent claims from denying as part of consolidated billing. Although CMS removed the requirement for facilities to verify whether a patient is in a skilled nursing facility Part A stay, modifier CB is only used when it has been determined that the beneficiary has ESRD entitlement, the tests are related to dialysis treatment and not included in the dialysis facility’s composite rate payment, and that the ordering physician is providing care in the dialysis facility.

The Centers for Medicare & Medicaid Services (CMS), Publication 100-02, Chapter 11, Section 30.2.2 lists CPT code 84295 as excluded from the composite rate for hemodialysis, intermittent peritoneal dialysis (IPD), continuous cycling peritoneal dialysis (CCPD) and hemofiltration patients. This same section also lists CPT code 82435 (Chloride; blood) as excluded from the composite rate for CAPD (Continuous ambulatory peritoneal dialysis) patients. Therefore, providers who are billing for the scenario outlined in the section above for CPT codes 84295 and/or 82435 with ICD-9-CM code 585.6 should begin appending the modifier CF for claims processed on or after July 15, 2010, for services rendered on or after October 1, 2006.