N.M. Admin. Code § 8.325.2.12

Current through Register Vol. 36, No. 1, January 14, 2025

Section 8.325.2.12 - COVERED SERVICES

Medicaid covers renal dialysis services for the first three months of dialysis pending the establishment of medicare eligibility. Medicare becomes the primary reimbursement source for individuals who meet the medicare eligibility criteria. Dialysis providers must assist medicaid recipients in applying for and pursuing final medicare eligibility determinations. Medicaid covers medically necessary dialysis supplies furnished to home-dialyzed recipients. Medicaid covers medically necessary renal dialysis services furnished by providers as required by the condition of the recipient. Medicaid covers the following specific renal dialysis services:

A. Supplies, equipment and services included in the renal dialysis services composite rate: The facility reimbursement fee includes all renal-related facility and home dialysis services, including supplies and equipment. The following are some of the drugs, items and supplies included in the facility fee:

(1) hypertonic saline;

(2) dextrose (glucose);

(3) mannitol or similar product used for volume control;

(4) heparin;

(5) protamine;

(6) antiarrhythmics;

(7) antihistamines;

(8) antihypertensives;

(9) pressor drugs;

(10) antibiotics (when used at home by a patient to treat an infection of the catheter site or peritonitis associated with peritoneal dialysis);

(11) oxygen;

(12) filters;

(13) bicarbonate dialysate;

(14) cardiac monitoring;

(15) catheters and catheter changes;

(16) suture removal kits and suture removal;

(17) dressing supplies;

(18) crash cart usage for cardiac arrest;

(19) declotting of shunt performed by facility staff in the dialysis unit;

(20) staff time to administer blood;

(21) staff time to administer separately billable parenteral items; and

(22) staff time used to collect all specimens for laboratory tests.

B. Routine laboratory tests: Routine laboratory tests are included in the facility fee. The following list specifies the covered routine tests and allowed frequencies. Routine tests at greater frequencies are reimbursable in addition to the facility fee but require medical justification by a physician.

(1) For hemodialysis, peritoneal dialysis and continuous cyclic peritoneal dialysis (CCPD):

(a) per dialysis:

(i) hematocrit;

(ii) clotting time;

(iii) hemoglobin.

(b) weekly:

(i) prothrombin time for patients on anticoagulant therapy;

(ii) creatinine; and

(iii) BUN;

(c) monthly:

(i) CBC;

(ii) calcium;

(iii) potassium;

(iv) chloride;

(v) alkaline phosphatase;

(vi) SGOT;

(vii) bicarbonate;

(viii) phosphate;

(ix) total protein;

(x) albumin; or

(xi) LDH.

(2) For continuous abdominal peritoneal dialysis when the facility bills a facility charge (CAPD): Monthly: BUN; magnesium; HCT; calcium; HGB; albumin; creatinine; phosphate; LDH; sodium; potassium; SGOT; CO₂; total protein; dialysate protein; alkaline phosphatase.

N.M. Admin. Code § 8.325.2.12

2/1/95; 8.325.2.12 NMAC - Rn, 8 NMAC 4.MAD.761.3 & A, 11/1/04, Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024