Dialysis Billing Manual | Department of Health Care Policy and Financing

Dialysis
Billing Information
Dialysis Benefits
Reimbursement
UB-04 Paper Claim Reference Table
Timely Filing
Institutional Provider Certification
Dialysis Revisions Log

Dialysis

Providers must be enrolled as a Health First Colorado (Colorado's Medicaid program) provider in order to:

Treat a Health First Colorado member
Submit claims for payment to Health First Colorado

Health First Colorado provides hemodialysis and peritoneal dialysis benefits to eligible members in outpatient, state-approved freestanding dialysis treatment centers and the home setting. These services are billed on the UB-04 institutional paper claim form or as an 837 Institutional (837I) electronic transaction.

State-approved non-routine services provided outside of the routine dialysis treatment should be billed and reimbursed separately. The services must be billed on the CMS 1500 professional paper claim form or as an 837 Professional (837P) electronic transaction using the dialysis center National Provider Identifier (NPI) number.

Providers should refer to the Code of Colorado Regulations, Program Rules (10 C.C.R. 2505-10 8.310), for specific information when providing dialysis services.

Dialysis may be provided as part of inpatient hospital treatment and included in the hospital inpatient claim. Refer to the Dialysis Benefits section below.

Billing Information

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu for general billing information.

Dialysis Benefits

Inpatient Hospital:

Inpatient hemodialysis is a benefit when:

Hospitalization is required for an acute medical condition requiring hemodialysis treatment.
Hospitalization is required for a covered medical condition and the member receives regular maintenance outpatient hemodialysis treatment.
Hospitalization is required for placement or repair of the hemodialysis route (shunt or cannula).
Inpatient hemodialysis payment is included as part of the Diagnosis Related Group (DRG).

Hospital admissions solely for hemodialysis are not a Health First Colorado benefit.

Outpatient: State-Approved Dialysis Treatment Center

A dialysis treatment center is an independent, free-standing center or a department of a licensed hospital enrolled as a dialysis center that is planned, organized, operated and maintained to provide outpatient hemodialysis treatment and/or training for home use of hemodialysis or peritoneal equipment. Other conditions for participation are those specifically entered into the agreement with the Department of Health Care Policy & Financing (the Department).

Continued outpatient hemodialysis is a benefit when:

Training of the eligible recipient to perform self-treatment in the home environment is contraindicated.
The eligible member is not a proper candidate for self-treatment in a home environment.
The home environment of the eligible member contraindicates self-treatment.
The eligible member is awaiting a kidney transplant.

Home Dialysis

The high costs of dialysis treatments and the budgetary limitations of Health First Colorado require that all members be considered for the most cost-efficient method of dialysis based upon their individual medical diagnosis and condition. Such treatments include home hemodialysis and peritoneal dialysis.

The participating dialysis center shall be responsible for the provision and maintenance of all equipment and necessary fixtures required for home dialysis and the provision of all supplies.

All eligible members approved for self-treatment must be trained in the use of hemodialysis or peritoneal equipment while undergoing outpatient treatments.

Training must be provided by qualified personnel of a hospital with a separate dialysis center or by qualified personnel of an independent, free-standing dialysis treatment center.

The participating dialysis center must provide and install quality hemodialysis equipment or peritoneal equipment to be used by the member at home and must provide routine medical surveillance of the member's adaptation and adjustment to the self-treatment.

Any facility providing regularly scheduled outpatient dialysis treatments or billing for supplies necessary to perform the various types of home dialysis treatments shall apply for a separate Health First Colorado Provider ID. Such provider shall be designated solely for the purpose of claims submission for dialysis services.

For appropriate reimbursement, Condition Code 74 must be used on home dialysis claims.

Emergency Medicaid and End-Stage Renal Disease

Effective February 1, 2019, End-Stage Renal Disease (ESRD) is considered an emergency medical condition for purposes of coverage under EMS. Recipients of EMS can receive care and services related to the treatment of ESRD, including but not limited to scheduled dialysis at a free-standing facility, home dialysis, and vascular access procedures.

An emergency medical condition is defined as "a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

Placing the patient's health in serious jeopardy,
Serious impairment to bodily function, or
Serious dysfunction of any bodily organ or party"42 U.S.C. § 1396b(v)(3), Colorado Revised Statutes § 24-76.5-102(1).

Recipients of Emergency Medicaid Services can receive care and services related to the treatment of ESRD at independent, free-standing dialysis centers.

Benefits for vascular access procedures and pre-surgery imaging are considered to be necessary in the treatment of ESRD.

Dialysis is not a covered benefit in the outpatient hospital setting.

As of January 1, 2022, home dialysis is a covered benefit for recipients of Emergency Medicaid.

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down for emergency services billing guidance.

Reimbursement

The amount of payment for outpatient dialysis or necessary supplies for home dialysis treatments, when provided by a separate dialysis center within a hospital or an independent, free-standing dialysis treatment center approved for participation by the Department, shall be the lesser of the dialysis center's charges or the currently posted Health First Colorado rate.

The following dialysis services are reimbursed at the lower of the composite Medicare rate ceiling or the individual center's Medicare facility rate:

Outpatient hemodialysis
Outpatient peritoneal dialysis
Continuous Ambulatory Peritoneal Dialysis (CAPD)
Continuous Cycling Peritoneal Dialysis (CCPD)

There is no reimbursement for home dialysis, except for necessary home dialysis equipment and supplies.

Routine Services

Routine services performed with the dialysis treatment shall be considered part of the composite rate and billed on the UB-04 claim form or electronically on the 837I transaction.

Report routine services with appropriate revenue codes. Refer to Appendix Q on the Billing Manuals web page under the Appendices drop-down for valid dialysis revenue codes.

Charges by a dialysis facility for routine drugs and laboratory services, electrocardiograms (EKGs) and X-rays are considered part of the dialysis treatment.

Non-Routine Services

Non-routine services performed in addition to the dialysis treatment shall be reimbursed separately and billed on the CMS 1500 professional claim form or electronically as an 837P transaction. This requires that the provider use the appropriate Healthcare Common Procedure Coding System (HCPCS) codes designated for the service provided. Only non-routine services performed in addition to the dialysis treatment may be included on the professional claim.

The amount of payment for non-routine outpatient dialysis treatments, when provided by a separate dialysis center within a hospital or an independent, free-standing dialysis treatment center, shall be based upon the Health First Colorado fee schedule.

Non-routine drugs must be billed on the CMS 1500 professional paper claim form or as an 837 Professional (837P) electronic transaction using the dialysis center NPI number.
Drugs not dispensed by the dialysis provider are billed by and reimbursed to the dispensing pharmacy.
Physician's charges for EKG or X-ray services must be billed by the physician.
A physician must supervise the process when blood is furnished and may bill for any professionally rendered covered service using their NPI number

Laboratory Services

Routine laboratory services are included as part of the dialysis service reimbursement.
Non-routine laboratory services are reimbursed as laboratory services separate from the dialysis treatment. Hospitals having separate dialysis units must submit services according to outpatient hospital laboratory regulations and UB-04 institutional billing instructions.
A freestanding dialysis center that performs its own laboratory tests must be licensed as an independent clinical laboratory and enrolled in Health First Colorado as an independent laboratory. The non-routine laboratory services must be billed under the independent laboratory's NPI number on the CMS 1500 professional claim form or electronically as an 837P transaction.
If an outside laboratory provides the service, that laboratory must bill for the service. All routine laboratory services performed by a dialysis treatment facility, with the designation as a certified clinical laboratory, or as a certified independent laboratory are included as part of the dialysis treatment reimbursement. All routine tests must be performed by the facility, with designation as a certified clinical laboratory, and reimbursed as part of the composite rate or performed by a certified independent outside laboratory and billed to the facility performing the dialysis treatment.

The following procedures and drugs constitute routine services. These services are included as part of the dialysis center’s composite rate.

Routine Labs / Procedures

Alkaline Phosphatase

All Hematocrit and Clotting time tests

Aspartate Aminotransferase (AST) or Serum Glutamic-Oxaloacetic Transaminase

Assay of Parathormone

Automated battery of tests (SMA-12)

Bicarbonate Dialysate

Blood Urea Nitrogen (BUN)

Complete Blood Count (CBC)

Carbon Dioxide (CO2)

Dialysate Protein

Electrolyte panel

Hematocrit

Hemoglobin

Hepatic function panel

Iron

Lactate Dehydrogenase (LDH)

Magnesium

Metabolic panel

Platelet Count

Red Blood Count

Renal function panel

Reticulocyte

Saline Flush

Serum Albumin

Serum Aluminum

Serum Bicarbonate

Serum Calcium

Serum Chloride

Serum Creatinine

Serum Ferritin

Serum Phosphorous

Serum Potassium

Serum Sodium

Specimen Collection

Total Protein

Transferrin

Vitamin D

White Blood Count

Routine Drugs

Calcitriol

Darbepoetin alfa, Epoetin alfa, or Epogen

Doxercalciferol

Hematinics

Heparin

Iron dextran, Iron sucrose, Sodium ferric gluconate complex in sucrose injection, or Ferumoxytol

Oxygen

Paricalcitol

Parsabiv (etelcalcetide)

Nonparenteral items may not be billed separately by the dialysis center but may be billed directly to Health First Colorado by the supplier. Nonparenteral items administered during the dialysis treatment are reimbursed as part of the composite rate.

UB-04 Paper Claim Reference Table

The information in the following table provides instructions for completing form locators as they appear on the paper UB-04 claim form. Instructions for completing the UB-04 institutional claim form are based on the current National Uniform Billing Committee (NUBC) UB-04 Reference Manual. Unless otherwise noted, all data form locators on the UB-04 have the same attributes (specifications) for Health First Colorado as those indicated in the NUBC UB-04 Reference Manual.

All code values listed in the NUBC UB-04 Reference Manual for each form locator may not be used for submitting paper claims to Health First Colorado. The appropriate code values listed in this manual must be used when billing Health First Colorado.

The UB-04 Certification document must be completed and attached to all claims submitted on the paper UB-04. Completed UB-04 paper Health First Colorado claims, including hardcopy Medicare claims, should be mailed to the correct fiscal agent address listed in Appendix A located on the Billing Manuals web page under the Appendices drop-down.

Do not submit "continuation" claims. Each claim form has a set number of billing lines available for completion. Do not crowd more lines on the form.

Billing lines in excess of the designated number are not processed or acknowledged. Claims with more than one page may be submitted through the Provider Web Portal.

Bill with a date span (From and To dates of service) only if the service was provided every consecutive day within the span. The From and To dates must be in the same month.

The Paper Claim Reference Table below lists the required, optional and conditional form locators for submitting the paper UB-04 claim form to Health First Colorado.

Form Locator and Labels

Completion Format

Instructions

1. Billing Provider Name, Address, Telephone Number

Text

Required
Enter the provider or agency name and complete mailing address of the provider who is billing for the services:

Street/Post Office box
City
State
Zip Code

Abbreviate the state using standard post office abbreviations. Enter the telephone number.

2. Pay-to Name, Address, City, State

Text

Required only if different from form locator 1.
Enter the provider or agency name and complete mailing address of the provider who will receive payment for the services:

Abbreviate the state using standard post office abbreviations. Enter the telephone number.

Street/Post Office box
City
State
Zip Code

3a. Patient Control Number

Up to 20 characters: Letters, numbers or hyphens

Optional
Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).

3b. Medical Record Number

17 digits

Optional
Enter the number assigned to the member to assist in retrieval of medical records.

4. Type of Bill

3 digits

Required
For Psychiatric Residential Treatment Facility (PRTF), use Type of Bill (TOB) 89X.
Enter the three-digit number indicating the specific type of bill. The three-digit code requires one digit each in the following sequences: Type of facility, Bill classification and Frequency:

Digit 1	Type of Facility
1	Hospital
2	Skilled Nursing
3	Home Health Services
4	Religious Non-Medical Health Care Institution
6	Intermediate Care
7	Clinic (Rural Health/Federally Qualified Health Center (FQHC)/Dialysis Center)
8	Special Facility (Hospice, Residential Treatment Centers [RTCs])
Digit 2	Bill Classification (Except Clinics and Special Facilities):
1	Inpatient (Including Medicare Part A)
2	Inpatient (Medicare Part B only)
3	Outpatient
4	Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
5	Intermediate Care Level I
6	Intermediate Care Level II
7	Sub-Acute Inpatient (Revenue Code 019X required with this bill type)
8	Swing Beds
9	Other
Digit 2	Bill Classification (Clinics Only):
1	Rural Health/FQHC
2	Hospital-Based or Independent Renal Dialysis Center
3	Freestanding
4	Outpatient Rehabilitation Facility (ORF)
5	Comprehensive Outpatient Rehabilitation Facilities (CORFs)
6	Community Mental Health Center
Digit 2	Bill Classification (Special Facilities Only):
1	Hospice (Non-Hospital Based)
2	Hospice (Hospital-Based)
3	Ambulatory Surgery Center
4	Freestanding Birthing Center
5	Critical Access Hospital
6	Residential Facility
Digit 3	Frequency:
0	Non-Payment/Zero Claim
1	Admit through discharge claim
2	Interim - First claim
3	Interim - Continuous claim
4	Interim - Last claim
7	Replacement of prior claim
8	Void of prior claim

5. Federal Tax Number

None

Submitted information is not entered into the claim processing system.

6. Statement covers period From/Through

From:6 digits MMDDYY
Through: 6 digits MMDDYY

Required
This form locator must reflect the beginning and ending dates of service. When span billing for multiple dates of service and multiple procedures, complete form locator 45 (Service Date). Providers not wishing to span bill following these guidelines must submit one claim per date of service. "From" and "Through" dates must be the same. All line-item entries must represent the same date of service.

8a. Patient Identifier

Text

Submitted information is not entered into the claim processing system.

8b. Patient Name

Up to 25 characters, letters and spaces

Required
Enter the member's last name, first name and middle initial.

9a. Patient Address - Street

Characters letters and numbers

Required
Enter the member's street/post office box as determined at the time of admission.

9b. Patient Address - City

Text

Required
Enter the member's city as determined at the time of admission.

9c. Patient Address - State

Text

Required
Enter the member's state as determined at the time of admission.

9d. Patient Address - ZIP

Digits

Required
Enter the member's zip code as determined at the time of admission.

9e. Patient Address - Country Code

Digits

Optional

10. Birthdate

8 digits (MMDDCCYY)

Required
Enter the member's birthdate using two digits for the month, two digits for the date, and four digits for the year (MMDDCCYY format). Example: 01012010 for January 1, 2010

11. Patient Sex

1 letter

Required
Enter an M (male) or F (female) to indicate the member's sex.

12. Admission Date

6 digits

Not Required

13. Admission Hour

6 digits

Not required

14. Admission Type

1 digit

Not Required

15. Source of Admission

1 digit

Required

16. Discharge Hour

2 digits

Not Required

17. Patient Discharge Status

2 digits

Required

Dialysis must use code 01.

18-28. Conditions Codes

2 digits

Conditional

Complete with as many codes necessary to identify conditions related to this bill.

Condition Codes
06 ESRD member - First 18 months entitlement

Renal dialysis settings
71 Full care unit
72 Self-care unit
73 Self-care training
74 Home care
75 Home care - 100 percent reimbursement

29. Accident State

2 digits

Optional

31 - 34. Occurrence Code/Date

2 digits and 6 digits

Conditional
Complete both the code and date of occurrence.
Enter the appropriate code and the date on which it occurred. Enter the date using MMDDYY format.
Occurrence Codes:

1	Accident/Medical Coverage
2	Auto Accident - No Fault Liability
3	Accident/Tort Liability
4	Accident/Employment Related
5	Other Accident/No Medical Coverage or Liability Coverage
6	Crime Victim
20	Date Guarantee of Payment Began
24*	Date Insurance Denied
25*	Date Benefits Terminated by Primary Payer
26	Date Skilled Nursing Facility Bed Available
27	Date of Hospice Certification or Recertification
40	Scheduled Date of Admission (RTD)
50	Medicare Pay Date
51	Medicare Denial Date
53	No longer used
55	Insurance Pay Date
A3	Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer A indicated in form locator 50.
B3	Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer B indicated in form locator 50.
C3	Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer C indicated in form locator 50.

*Other Payer occurrence codes 24 and 25 must be used when applicable. The claim must be submitted with the third-party information

35-36. Occurrence Span Code From/ Through

Digits

Leave blank

38. Responsible Party Name/Address

None

Leave blank

39-41. Value Codes and Amounts

2 characters and up to 9 digits

Conditional
Enter appropriate codes and related dollar amounts to identify monetary data or number of days using whole numbers necessary for the processing of this claim. Never enter negative amounts. Codes must be in ascending order. If a value code is entered, a dollar amount or numeric value related to the code must be entered.
Most Common Codes:

01	Semiprivate Rate (Accommodation Rate)
06	Medicare Blood Deductible
14	No Fault Including Auto/Other
15	Worker's Compensation
31	Member Liability Amount*
32	Multiple Member Ambulance Transport
37	Pints of Blood Furnished
38	Blood Deductible Pints
40	New Coverage Not Implemented by HMO
45	Accident Hour Enter the hour when the accident occurred that necessitated medical treatment. Use the same coding used in form locator 18 (Admission Hour).
49	Hematocrit Reading - EPO Related
58	Arterial Blood Gas (PO2/PA2)
68	Erythropoietin (EPO)-Drug
80	Covered Days
81	Non-Covered Days
Enter the deductible amount applied by indicated payer: A1 Deductible Payer A B1 Deductible Payer B C1 Deductible Payer C
Enter the amount applied to member's co-insurance by indicated payer: A2 Coinsurance Payer A B2 Coinsurance Payer B C2 Coinsurance Payer C
Enter the amount paid by indicated payer: A3 Estimated Responsibility Payer A B3 Estimated Responsibility Payer B C3 Estimated Responsibility Payer C

42. Revenue Code

4 digits

Required

Enter the revenue code that identifies the specific service provided. List revenue codes in ascending order. Refer to Appendix Q on the Billing Manuals web page under the Appendices drop-down for valid dialysis revenue codes.

A revenue code must appear only once per date of service. * If more than one of the same services is provided on the same day, combine the units and charges on one line accordingly.

Complete with as many codes as necessary to identify conditions related to this bill.

43. Revenue Code Description

Text

Required
Enter the revenue code description or abbreviated description.
When reporting a National Drug Code (NDC):

Enter the NDC qualifier of "N4" in the first two positions on the left side of the field, immediately followed by the 11-digit NDC numeric code.
Enter one space for separation.
Enter the NDC unit of measure qualifier. Examples include:
- F2 - International Unit
- GR - Gram
- ML - Milliliter
- UN - Units
Enter one period for separation.
Enter the quantity (number of NDC units).

Example:

42 REV.CD.	43 DESCRIPTION
0636	N467066000501 ME.016

44.HCPCS/Rates/Health Insurance Prospective Payment System (HIPPS) Rate Codes

5 digits

Conditional

Enter only the HCPCS code for each detail line. Use approved modifiers listed in this section for hospital-based transportation services.

Complete for laboratory, radiology, physical therapy, occupational therapy and hospital-based transportation. When billing HCPCS codes, the appropriate revenue code must also be billed.

Services Requiring HCPCS
Anatomical Laboratory: Bill with TC modifier
Hospital-Based Transportation
Outpatient Laboratory: Use only HCPCS 80000s-89000s.
Outpatient Radiology Services

Enter HCPCS and revenue codes for each radiology line. The only valid modifier for outpatient radiology is TC. Refer to the annual HCPCS bulletin for instructions, located on the Bulletins web page.

With the exception of outpatient lab and hospital-based transportation, outpatient radiology services can be billed with other outpatient services.

HCPCS codes must be identified for the following revenue codes:

030X Laboratory
032X Radiology - Diagnostic
033X Radiology - Therapeutic
034X Nuclear Medicine
035X CT Scan
040X Other Imaging Services
042X Physical Therapy
043X Occupational Therapy
054X Ambulance
061X MRI and MRA

HCPCS codes cannot be repeated for the same date of service. Combine the units in form locator 46 (Units) to report multiple services.

45. Service Date

6 digits

For span bills only:
Enter the date of service using MMDDYY format for each detail line completed.

Each date of service must fall within the date span entered in the "Statement Covers Period" field (form locator 6).

46. Service Units

3 digits

Required
Enter a unit value on each line completed. Use whole numbers only. Do not enter fractions or decimals and do not show a decimal point followed by a 0 to designate whole numbers (e.g., Do not enter 1.0 to signify one unit).

For span bills, the units of service reflect only those visits, miles or treatments provided on dates of service in form locator 45.

47. Total Charges

9 digits

Required

Enter the total charge for each line item. Calculate the total charge as the number of units multiplied by the unit charge. Do not subtract Medicare or third-party payments from line charge entries. Do not enter negative amounts. A grand total on line 23 is required for all charges.

48. Non-covered Charges

Up to 9 digits

Conditional

Enter incurred charges that are not payable by Health First Colorado.

Non-covered charges must be entered in both form locator 47 (Total Charges) and form locator 48 (Non-Covered Charges). Each column requires a grand total on line 23.

Non-covered charges cannot be billed for outpatient hospital laboratory or hospital-based transportation services.

50. Payer Name

1 letter and text

Required

Enter the payment source code followed by name of each payer organization from which the provider might expect payment.
At least one line must indicate Health First Colorado.

Source Payment Codes
B	Workmen's Compensation
C	Medicare
D	Health First Colorado
E	Other Federal Program
F	Insurance Company
G	Blue Cross, including Federal Employee Program
I	Other
Line A	Primary Payer
Line B	Secondary Payer
Line C	Tertiary Payer

51. Health Plan ID

10 digits

Required
Enter the NPI number assigned to the billing provider. Payment is made to the enrolled provider or agency that is assigned this number.

52. Release of Information

N/A

Submitted information is not entered into the claim processing system.

53. Assignment of Benefits

N/A

Submitted information is not entered into the claim processing system.

54. Prior Payments

Up to 9 digits

Conditional
Complete when there are Medicare or third-party payments.
Enter third party and/or Medicare payments.

55. Estimated Amount Due

Up to 9 digits

Conditional
Complete when there are Medicare or third-party payments.
Enter the net amount due from Health First Colorado after provider has received other third party, Medicare or member liability amount.
Medicare Crossovers
Enter the sum of the Medicare coinsurance plus Medicare deductible less third-party payments and member payments.

56. National Provider Identifier (NPI)

10 digits

Required
Enter the billing provider's 10-digit National Provider Identifier (NPI).

57. Other Provider ID

Optional
Submitted information is not entered into the claim processing system.

58. Insured's Name

Up to 30 characters

Required
Enter the member's name on the Health First Colorado line.
Other Insurance/Medicare
Complete additional lines when there is third party coverage. Enter the policyholder's last name, first name and middle initial.

60. Insured's Unique ID

Up to 20 characters

Required
Enter the insured's unique identification number assigned by the payer organization exactly as it appears on the health insurance card. Include letter prefixes or suffixes shown on the card.

61. Insurance Group Name

14 letters

Conditional
Complete when there is third party coverage.

Enter the name of the group or plan providing the insurance to the insured exactly as it appears on the health insurance card.

62. Insurance Group Number

17 digits

Conditional
Complete when there is third party coverage.

Enter the identification number, control number or code assigned by the carrier or fund administrator identifying the group under which the individual is carried.

63. Treatment Authorization Code

Up to 18 characters

Conditional
Complete when the service requires a Prior Authorization Request (PAR).
Enter the authorization number in this form locator if a PAR is required and has been approved for services.

64. Document Control Number

none

Conditional

65. Employer Name

Text

Conditional
Complete when there is third party coverage.
Enter the name of the employer that provides health care coverage for the individual identified in form locator 58 (Insured Name).

66. Diagnosis Version Qualifier

Submitted information is not entered into the claim processing system.
Enter applicable International Classification of Diseases (ICD) indicator to identify which version of ICD codes is being reported.
0ICD-10-CM (DOS 10/1/15 and after)

67. Principal Diagnosis Code

Up to 6 digits

Not required

67A. - 67Q. - Other Diagnosis

6 digits

Optional
Enter the exact diagnosis code corresponding to additional conditions that co-exist at the time of admission or develop subsequently and which effect the treatment received or the length of stay. Do not add extra zeros to the diagnosis code.

69. Admitting Diagnosis Code

6 digits

Not required

70. Patient Reason Diagnosis

Submitted information is not entered into the claim processing system.

71. PPS Code

Submitted information is not entered into the claim processing system.

72. External Cause of Injury code (E-Code)

6 digits

Optional
Enter the diagnosis code for the external cause of an injury, poisoning or adverse effect. This code must begin with an "E."

74. Principal Procedure Code/Date

7 characters and 6 digits

Conditional

Enter the ICD-10-CM procedure code for the principal procedure performed during this billing period and the date on which procedure was performed. Enter the date using MMDDYY format. Apply the following criteria to determine the principal procedure:

The principal procedure is not performed for diagnostic or exploratory purposes. This code is related to definitive treatment.

The principal procedure is most related to the primary diagnosis.

74A. Other Procedure Code/Date

7 characters and 6 digits

Conditional

Complete when there are additional significant procedure codes.

Enter the procedure codes identifying all significant procedures other than the principal procedure and the dates on which the procedures were performed. Report those that are most important for the episode of care and specifically any therapeutic procedures closely related to the principal diagnosis. Enter the date using MMDDYY format.

76. Attending NPI - Required

NPI - 10 digits

Health First Colorado ID Required
NPI - Enter the 10-digit NPI number assigned to the physician having primary responsibility for the member's medical care and treatment. This number is obtained from the physician and cannot be a clinic or group number.
(If the attending physician is not enrolled in Health First Colorado, or if the member leaves the ER before being seen by a physician, the hospital may enter their individual numbers.)
Hospitals and FQHCs may enter the member's regular physician's 10- digit NPI in the Attending Physician ID form locator if the locum tenens physician is not enrolled in Health First Colorado.
QUAL - Enter "1D" for Health First Colorado
Enter the attending physician's last and first name.
This form locator must be completed for all services.

77. Operating NPI

Not required
Submitted information is not entered into the claim processing system.

78 - 79. Other ID

NPI - 10 digits

Conditional

Complete when attending physician is not the Primary Care Provider (PCP) or to identify additional physicians.

Ordering, Prescribing, or Referring Provider NPI - when applicable

NPI - Enter up to two 10-digit NPI numbers when applicable. This form locator identifies physicians other than the attending physician. If the attending physician is not the PCP or if a clinic is a PCP agent, enter the PCP NPI number as the referring physician. The name of the Health First Colorado member's PCP appears on the eligibility verification. Review either for eligibility or PCP. Health First Colorado does not require that the PCP number appear more than once on each claim submitted.

The attending physician's last and first name are optional.

80. Remarks

Text

Enter specific additional information necessary to process the claim or fulfill reporting requirements.

81. Code - QUAL/CODE/VALUE (a-d)

Qualifier: 2 digits
Taxonomy Code: 10 digits

Optional

Complete both the qualifier and the taxonomy code for the billing provider in field 81CC-a.

Field 81CC-a must be billed with qualifier B3 for the taxonomy code to be captured in the claims processing system. If B3 is missing, no taxonomy code will be captured in the claims processing system.
Only one taxonomy code can be captured from field 81CC. If more than one taxonomy code is provided, only the first instance of B3 and taxonomy code will be captured in the claims processing system.

Dialysis UB-04 Claim Example

dialysis Claim Example

Dialysis UB-04 Crossover Claim Example

dialysis crossover claim Example

Timely Filing

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down for more information on timely filing policy, including the resubmission rules for denied claims.

Institutional Provider Certification

The Institutional Provider Certification form is available on the Provider Forms web page under the Claim Forms and Attachments drop-down menu.

Dialysis Revisions Log

Revision Date	Section/Action	Made by
12/1/2016	Manual revised for interChange implementation. For manual revisions prior to 12/01/2016, please refer to Archive.	HPE (now DXC)
12/27/2016	Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_2.xlsx	HPE (now DXC)
1/10/2017	Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_3.xlsx	HPE (now DXC)
1/19/2017	Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_4.xlsx	HPE (now DXC)
1/26/2017	Updates based on Department 1/20/2017 approval email	HPE (now DXC)
3/13/2017	Updated the Type of Bill section in the Paper Claims Table to reflect the NUBC manual	HCPF
5/26/2017	Updates based on Fiscal Agent name change from HPE to DXC	DXC
1/2/2018	Revenue Code Submission Update - instructions for reporting an NDC	DXC
6/25/2018	Updated billing and timely to point to general manual	HCPF
6/28/2018	Minor formatting edit	HCPF
1/22/2019	Many updates and clarifications were made throughout the billing manual. A section about "Emergency Medicaid & End-Stage Renal Disease" was added. The list of routine labs, procedures, and drugs was expanded.	HCPF
6/17/2019	Updated Appendices' links and verbiage	DXC
12/10/2019	Converted to web page	HCPF
8/7/2020	Updated item 81 of the Paper Claim Reference Table for taxonomy code billing	DXC
7/15/2021	Updated link for more ESRD emergency services information	HCPF
12/1/2021	Updated EMS ESRD to include home dialysis as of Jan. 1, 2022 Added condition code 74 language for home dialysis.	HCPF
5/11/2022	Updated routine and nonroutine section for clarity	HCPF
9/19/2023	Updated EMS ESRD to include vascular access procedures and pre-surgery imaging and made some minor edits for consistency	HCPF
1/26/2024	Added clarifying language under Emergency Medicaid and End-Stage Renal Disease	HCPF