Nephrology billing services

Billing risks

Billing challenges in nephrology

Coding detail

Coding detail for nephrology

Most nephrology revenue questions come back to three things: what month it is, where the patient dialyzed, and who furnished the visits. The rules below are Medicare’s; Medicaid and commercial plans publish their own.

ESRD monthly capitation for center-based patients

Codes 90951–90962 are selected by age band (under 2, 2–11, 12–19, and 20 and older) and by the number of face-to-face visits in the month. Visits count when furnished by a physician, nurse practitioner, physician assistant, or clinical nurse specialist. Other practitioners in the same group may furnish some visits, but the practitioner who performs the complete assessment and establishes the plan of care bills the month. Inpatient visits do not count toward the tier; visits to patients in observation status or residing in a skilled nursing facility do. Dates of service span the month, and the first month runs from the day dialysis begins.

Home dialysis, partial months, and telehealth

Home dialysis is billed per full month with 90963–90966. The per-day codes 90967–90970 are reserved for home patients with less than a full month, transient patients, partial months where a complete assessment was not furnished before hospitalization, transplant, or death, and a permanent change of managing physician. When monthly visits for center-based patients are furnished by telehealth, at least one visit each month must be hands-on to examine the vascular access site. Home dialysis patients may choose telehealth for their monthly clinical assessments, with in-person assessments required monthly for the first three months of home dialysis and at least once every three consecutive months after that.

CKD visits and diagnosis coding

Office visits for CKD are leveled on medical decision making or total time, and the G2211 complexity add-on may apply when your practice provides ongoing care for the patient’s kidney disease. Diagnosis codes should carry the documented stage (N18.31 and N18.32 for stages 3a and 3b, N18.6 for end-stage renal disease) with Z99.2 when the patient depends on dialysis. ICD-10-CM presumes a link between hypertension and CKD, so the combination codes apply unless the provider documents that they are unrelated. Medicare also covers kidney disease education (G0420 and G0421) for stage IV patients, up to six sessions per lifetime, on referral from the managing physician.

Access procedures and inpatient dialysis

Dialysis circuit work is reported with one primary code per session (36901–36906), chosen by the most intensive service in the peripheral segment, and the imaging guidance is included. Central-segment angioplasty, stenting, and embolization are add-ons (36907–36909). For inpatient hemodialysis (90935 and 90937), evaluation and management related to the dialysis or renal failure on the same day is included; a significant, separately identifiable, unrelated visit needs modifier 25 support in the note.

Medicare, Medicare Advantage, and employer coverage

Monthly ESRD services are paid under Part B at 80 percent of the approved amount after the deductible, and the patient owes the 20 percent coinsurance. When a patient qualifies for Medicare because of ESRD and also has employer group coverage, the group plan generally pays first for a 30-month coordination period. Since 2021, people with ESRD can join Medicare Advantage plans, which apply their own authorization requirements and policies.

Billing rules above reference public CMS guidance; key sources reviewed 2026-10-21.

General educational information, not legal advice or a guarantee of reimbursement. Requirements vary by payer, plan, setting and date of service.
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