99512
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Diagnosis documentation: medical record documenting diagnosis of end-stage renal disease (ESRD) and indication for renal replacement therapy.
- Clinical stability: documentation that the individual is 'stable on dialysis' (clinical notes, dialysis session records) and notation that no skilled care interventions are required during routine treatments for coverage without skilled care.
- Training records: evidence of comprehensive training completion for the patient and/or non-professional caregiver (e.g., completed course CPT 90989 or per-session 90993 where applicable), including competency assessment.
- Caregiver capability: documentation that a non-professional caregiver is available, trained, and able to assist (if applicable) or documentation that patient/caregiver is not capable (for skilled care pathway).
Key Coverage Criteria
- Home hemodialysis (HHD) as an alternative to facility-based hemodialysis for individuals with end-stage renal disease (ESRD) who meet ALL of the following (HHD without skilled care): individual is stable on dialysis with no evidence of skilled care interventions being necessary during treatments; and the individual undergoing hemodialysis or a non-professional caregiver has the ability to perform and maintain home hemodialysis and has received comprehensive training regarding proper protocol; an [...]
- Home hemodialysis WITH skilled care as an alternative to facility-based hemodialysis for individuals with ESRD who meet ALL of the following: individual is stable on dialysis and not at increased risk as a result of having the procedure performed outside a dialysis center venue; and the individual undergoing hemodialysis or non-professional caregiver is NOT capable of performing home hemodialysis; and the individual has medical contraindications to leaving home for hemodialysis; and individual h [...]
- HHD for pediatric patients as applicable under ESRD-related services codes (CPT 90963–90969) when the patient meets the general coverage rationale and age-specific CPT definitions apply (codes listed in policy for reference).
- Services and per-diem administrative/care coordination/supplies for home hemodialysis (HCPCS S9335) when provided as described and when member meets coverage criteria and benefit plan provisions (codes listed in policy for reference).
- Hemodialysis or intermittent peritoneal dialysis for renal failure up to 3 times per week.
- Hemodialysis and intermittent peritoneal dialysis performed more than 3 times per week for renal failure when one or more of the following conditions are present and refractory to dialysis 3 times per week: hyperkalemia (E87.5), hypophosphatemia (E83.39), pregnancy (O00.0-O9A.53; Z33.1; Z33.3; Z3A.00-Z3A.49), fluid overload (E87.70-E87.79), acute pericarditis (I30.0-I30.9), congestive heart failure (I50.1-I50.9), pulmonary edema (J81.0-J81.1), or severe catabolic state/age-related physical debil [...]
6 Active Policies
AETNA-CPB-0201 — Skilled Home Health Care Nursing Services
AETNA-CPB-0541 — Dialysis
UHC-POL-home-hemodialysis — Home Hemodialysis
UMR-POL-UMR-home-hemodialysis — Home Hemodialysis
SUREST-POL-SUREST-home-hemodialysis — Home Hemodialysis
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.