Home Dialysis Coverage Overview

Published 05/10/2024

For individuals with end-stage renal disease (ESRD), hemodialysis (HD) is an option for "renal replacement" therapy. The ESRD facility is responsible for the overall management of the home dialysis patient, including assuring that the patient is provided with equipment and supplies that are functional. This means the ESRD facility is responsible for delivering, installing, monitoring and maintaining supplies and equipment necessary to furnish all modalities of home dialysis. Conventional hemodialysis is performed three times a week for three to four hours or longer each time resulting, for some patients, in improved health, reduced symptoms, and a longer and higher quality of life. Home HD allows individuals to conduct treatment in the convenience of a home environment. 

Coverage Indications

Home hemodialysis without skilled care is proven and medically necessary as an alternative to facility-based hemodialysis for treating individuals with end-stage renal disease who meet all the following criteria: 

  • Individual is stable on dialysis with no evidence of Skilled Care interventions being necessary during treatments 
  • Individual undergoing HD or non-professional caregiver has the ability to perform and maintain home hemodialysis and has received comprehensive training regarding proper protocol 
  • Absence of complications and significant concomitant disease that would cause home HD to be unsafe or unsuitable
  • Presence of well-functioning vascular access 

Home hemodialysis with skilled care is proven and medically necessary as an alternative to facility-based hemodialysis for treating individuals with end-stage renal disease who meet all the following criteria: 

  • Individual is stable on dialysis and not at increased risk as a result of having the procedure performed outside a dialysis center venue
  • Individual has well-functioning vascular access
  • Individual has medical contraindications to leaving home for HD
  • Individual undergoing HD or non-professional caregiver is not capable of performing home hemodialysis
  • Staff assisted home hemodialysis protocols generally match those provided in the HD center (e.g., three times per week, three- to four-hour treatments). The exact dialysis therapy employed is determined on an individual basis by the attending nephrologist.

Some examples (but not an all-inclusive list) of renal dialysis items and services included in the ESRD PPS and may not be billed separately when furnished by an ESRD facility are:

  • Staff time used to administer blood;
  • Declotting of shunts and any supplies used;
  • Oxygen and the administration of oxygen; and
  • Staff time used to administer separately billable items

Documentation Requirements

  • Document in the medical record that the patient, the caregiver, or both received and demonstrated adequate comprehension of the training 
  • Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every two months 
  • Maintain this information in the patient's medical record

Common Denials Due to Missing Documentation

  • Treating provider’s comprehensive assessment or reassessment of the beneficiary relative to the DOS and developed by an interdisciplinary team
  • Plan of care for home dialysis relative to the billed DOS, developed by the team and signed by at least one team member and the beneficiary or their designee; or if the beneficiary did not sign, the reason is documented in the plan of care
  • Evaluation of nutritional status by a dietitian to support the dietitian's part of the interdisciplinary team assessment of the beneficiary in order to support ESRD monthly services for home dialysis billed for DOS 
  • Evaluation of psychosocial needs by a social worker relative to DOS to support the social worker's part of the interdisciplinary team assessment of the beneficiary in order to support ESRD monthly services for home dialysis billed

ESRD facilities furnishing dialysis in-facility or in a patient’s home are paid for a maximum of 13 treatments during a 30-day month and 14 treatments during a 31-day month unless there is medical justification for additional treatments.

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