End Stage Renal Dialysis (ESRD) Medicare Claims Processing Manual Clarification

The revisions are summarized as follows:

• If the ESRD patient also receives other hospital outpatient services on the same day as a specimen collection and/or laboratory test, then the patient is considered to be a registered hospital outpatient and cannot be considered to be a non-patient on that day for purposes of the specimen collection and laboratory test. When the patient does not also receive hospital outpatient services on the same day as the specimen collection and/or laboratory test, then the hospital may choose to register the beneficiary as an outpatient for the specimen collection or bill for these services as non-patient on the 14x bill type.
• Independent laboratories with the appropriate CLIA certification may be paid for ESRD clinical laboratory tests that are separately billable.
• When a hospital laboratory is billing for laboratory services ordered by an ESRD facility and the patient (beneficiary) is a SNF resident under a Part A stay, the hospital laboratory must use the “CB” modifier for those services excluded from consolidated billing.
• Beneficiaries in a SNF Part A stay are eligible for a broad range of diagnostic services. Physicians ordering medically necessary diagnostic tests that are not directly related to the beneficiary’s ESRD are subject to the SNF consolidated billing requirements. Physicians may bill the contractor for the professional component of these diagnostic tests. In most cases, however, the technical component of diagnostic tests is included in the SNF PPS rate and is not separately billable to the contractor.