Combatting ESRD Billing Complexity in Nephrology

Nephrology: End-Stage Renal Disease (ESRD) Billing Complexity 

Unique Challenges in Nephrology Revenue Cycle Management

Nephrology is an incredibly complex space, and that complexity doesn’t end on the clinical front. Back-end, nonclinical staff at nephrology practices face a slew of unique challenges when it comes to making sure the practice is getting reimbursed for treatments and procedures.

This is especially true when it comes to End-Stage Renal Disease (ESRD) patients and billing. These patients on dialysis pose unique challenges due to complex coding requirements and the various plans and programs involved in their care (such as medicare, medicaid, and medicare advantage).

Complex Dialysis Coding Requirements

Mirroring the complexity of the treatments themselves, billing and coding requirements in nephrology are both intricate and complex. Coding for dialysis treatments, diagnostic tests, surgeries, and consultative services require extreme detail.

For example, when billing for ESRD patients, coding often requires:

1. Condition codes - at least 1 is required per claim to describe the dialysis setting, if there were two dialysis during the month, then two claims must be filed. This could reflect full care in-unit, self care in-unit, training, at home, at backup facility, etc. Optional condition codes include non-primary ESRD facility, self administered anemia management, home dialysis in nursing facilities, and acute kidney injury (AKI) on a monthly basis, to name a few.
2. Occurrence codes - code 51 to indicate date of last Kt/V (K-dialyzer clearance of urea; t-dialysis time; V-patient’s total body water) reading, or code 33 to indicate first day of coordination period covered by employer group health plan (which must be used in combination with value code 13 when medicare is the secondary payer due to ESRD entitlement) 
3. Value codes / amounts - include hemoglobin reading, weight of patient, result of last Kt/V reading, etc.
4. Revenue codes - reflecting the amount of units administered, hemodialysis, peritoneal dialysis, etc.
5. HCPCS codes when applicable - such as for unlisted dialysis procedures, Aranesp injections, EPO injections, etc.

Managing a Mix of Providers and Systems

Adding to the complexity of coding requirements, these patients may see a number of providers when receiving care. These can include:

• Dialysis centers
• Nephrologists
• Vascular access surgeons
• And more

Each of these providers leverage different systems to record patient data and treatment information, requiring advanced coordination between multiple stakeholders and a range of systems and tools.

Documentation Constraints

Because of the intricacies required in coding, nephrologists need to take extremely detailed notes and accurate documentation — a task that becomes increasingly difficult when facing a high volume of complex patients and time constraints in between appointments. A lack of documentation leads to incorrect or incomplete codes, which can ultimately lead to denials and underpayments.

Prior Authorization and Benefits Eligibility

In nephrology, many treatments, advanced procedures, drugs, and lab tests require a prior authorization from the insurer. Not only can prior authorization requirements delay care, but ever-changing policies can result in claim denials.

The Revenue Cycle Platform to Solve Nephrology’s Most Complex Challenges

Adonis Intelligence was built by revenue cycle teams, for revenue cycle teams, to combat even the toughest challenges in nephrology billing. Intelligence ensures claim accuracy, predicts and prevents denials, flags payer prior authorization requirements, and provides a single source of truth across a range of technologies and systems. 

Learn how Adonis Intelligence is helping nephrology practices:  

1. Get paid faster, by predicting and mitigating denials
2. Collect more revenue, through underpayments detection and resolution
3. Save time, by intelligently identifying and addressing/actioning root cause issues
4. Stay ahead, through tracking and adapting to evolving payer policies