Ala. Admin. Code r. 560-X-6-.19

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-6-.19 - Physician Services For End Stage Renal Disease. (ESRD)

(1) All physician services rendered to each outpatient maintenance dialysis patient provided during a full month on an ongoing basis without interruption of the treatment regime (uninterruptedly) shall be billed on a monthly capitation basis. The monthly capitation payment is limited to once per month, per recipient, per provider.

(2) Physician services rendered to each outpatient maintenance dialysis patient not performed consecutively (interruptedly) during a full month, i.e., preceding and/or following the period of hospitalization, are allowed. Please refer to the physician's chapter of the provider Manual for further details.

(3) Services not covered by the monthly capitation payment (MCP) and which are reimbursed in accordance with usual and customary charge rules are limited to:

(a) Declotting of shunts.

(b) Covered physician services furnished to hospital inpatients by a physician who elects not to receive the MCP for these services.

(c) Nonrenal related physician services. These services may be furnished either by the physician providing renal care or by another physician. They may not be incidental to services furnished during a dialysis session or office visit necessitated by the renal condition.

(4) Refer to the Renal Dialysis chapter for further details.

Author: Brenda Vaughn, Program Manager, Medical Services Program

Ala. Admin. Code r. 560-X-6-.19

Emergency rule effective January 1, 1987. Permanent rule effective January 14, 1987. Amended effective March 12, 1987. Amended: Filed April 11, 2003; effective May 16, 2003.

Statutory Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §405.542 ; Federal Register dated July 2, 1986.