End-Stage Renal Disease (ESRD) Claims

Effective November 6, 2016, NCTracks will implement a new edit for End-Stage Renal Disease (ESRD) claims that will affect outpatient institutional claims billed by outpatient dialysis facilities and professional claims. The new edit will deny ESRD claims if the primary diagnosis is not ICD-9 code 585.6 or ICD-10 code N18.6. Claims that will need to have an ESRD primary diagnosis code are:

  • Outpatient institutional claims billed by outpatient dialysis facilities with billing taxonomy 261QE0700X submitting any of the following revenue codes: 0390, 0634, 0635, 0821, 0829, 0831, 0841, or 0851.
  • Professional claims with any taxonomy code submitting any of the following CPT codes: 90951 through 90970, 90989 or 90993.

Please note that within the portal, primary diagnosis is displayed as principle diagnosis on outpatient institutional claims. As for professional claims, the primary diagnosis is defined by pointer position 1. If the diagnosis requirement is not met, the claim will be denied with EOB 00291 - PRIMARY DIAGNOSIS FOR ESRD SERVICES MUST BE END STAGE RENAL DISEASE. The implementation applies to any claim submitted after November 6, 2016, regardless of the date of service listed on the claim. This change is not applicable to crossover claims, including part C claims.

Providers can refer to Skillport within the Provider Portal for computer-based training courses that show where to place the diagnosis codes on an institutional and professional claim. The courses are "How to File an Institutional Claim" and "How to File a Professional Claim."