A capitation payment is a fee or payment of a uniform amount per each person.

In regards to nephrology groups, Medicare’s monthly capitation payment is paid to physicians and practitioners for most of the outpatient dialysis-related services they provide to end-stage renal disease patients. The payment amount will vary based on the number of visits per month and age of the patient. It is important to note, a month equals a calendar month.

Services in the MCP include, but are not limited to, assessments and decisions regarding patient diet and nutrition, patients’ tolerance of dialysis, transplant qualification, dialysate, modality, access, dialysis related neuropathy, short and long-term care plans, and coordination with other care staffs. For a complete list, please see www.cms.gov.

Services excluded from the MCP and are separately billable include echocardiograms, 24-hour blood pressure monitor, biopsies, complete evaluations for renal transplantation, evaluation of potential living donors, services provided to the patient prior to dialysis, and the training of patients for home dialysis. Once again, you can see www.cms.gov for a more extensive list.

Each visit must be face-to-face by a physician, nurse practitioner, clinical nurse specialist, or by a physician assistant. However, the physician or practitioner who provides the comprehensive assessment for the month is the physician the bill should be under. If a non-physician performs the comprehensive visit for the month, it should then be billable under his/her individual PIN. All healthcare providers included in the care must be a partner, an employee of the same group practice, or an employee of the MCP physician or practitioner.

Large nephrology groups see each end-stage patient frequently. The care provided between the nephrology group and the patient is considered critical. For providers, these visits can be the difference between thousands of dollars each month. The chart below is for ESRD patients over the age of 20.

  4+ visits with CHD 2-3 Visits with CHD 1 CHD visit PD/HHD(Home dialysis patients)
CPT 90960 90961 90962 90966
Charge Amount $478.00 $401.00 $308.00 $400.00
Medicare Allowable $284.00 $238.00 $183.00 $237.00

PD and HHD patients require one face-to-face visit per month in order to bill. If a patient was at home part of the month and HD the other part, the corresponding CPT code would be 90966. One day at home counts as a full month at home. CPT 90989 is used for PD training, which is separately billable. This is a one-time charge for all patients starting dialysis in home for the first time.  The date of service used is the last day of PD training completed.

In an ever-changing healthcare world, the MCP places almost all of the risk on the healthcare providers. In a Fee-for-Service plan, doctors are encouraged to order a higher number of tests and procedures, therefore placing the risk on the patient and insurance companies. There has been a decline in Fee-for-Service systems in the last decade as new capitation systems provide more certainty to both providers and payers.

“Doctor, there’s a patient in the waiting room that says he’s invisible.” “Well, tell him I can’t see him right now.”