Page 288 - Medicare Benefit Policy Manual

Beneficiaries with CKD may benefit from kidney disease education (KDE) interventions
due to the large amount of medical information that could affect patient outcomes,
including the increasing emphasis on self-care and patients’ desire for informed,
autonomous decision-making. Pre-dialysis education can help patients achieve better
understanding of their illness, dialysis modality options, and may help delay the need for
dialysis. Education interventions should be patient-centered, encourage collaboration,
offer support to the patient, and be delivered consistently.

Effective for claims with dates of service on and after January 1, 2010, Section 152(b) of
the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) covers
KDE services under Medicare Part B. KDE services are designed to provide
beneficiaries with Stage IV CKD comprehensive information regarding: the management
of comorbidities, including delaying the need for dialysis; prevention of uremic
complications; all therapeutic options (each option for renal replacement therapy, dialysis
access options, and transplantation); ensuring that the beneficiary has opportunities to
actively participate in his/her choice of therapy; and that the services be tailored to meet
the beneficiary’s needs.

Regulations for KDE services were established at 42 CFR 410.48. Claims processing
instructions and billing requirements can be found in Pub. 100-04, Medicare Claims
Processing Manual, Chapter 32 – Billing Requirements for Special Services, Section 20.

310.1 - Beneficiaries Eligible for Coverage
(Rev. 117; Issued: 12-18-09; Effective Date: 01-01-10; Implementation Date: 04-
05-10)

Medicare Part B covers outpatient, face-to-face KDE services for a beneficiary that:

• is diagnosed with Stage IV CKD, using the Modification of Diet in Renal Disease
(MDRD) Study formula (severe decrease in GFR, GFR value of 15-29
2
mL/min/1.73 m ), and

• obtains a referral from the physician managing the beneficiary’s kidney condition.
The referral should be documented in the beneficiary’s medical records.

310.2 - Qualified Person
(Rev. 117; Issued: 12-18-09; Effective Date: 01-01-10; Implementation Date: 04-
05-10)

Medicare Part B covers KDE services provided by a ‘qualified person,’ meaning a:

• physician (as defined in section 30 of this chapter),

• physician assistant, nurse practitioner, or clinical nurse specialist (as defined in
sections 190, 200, and 210 of this chapter),