Documentation
End-stage renal disease (ESRD) services are provided per day in an outpatient setting when less than a full month of service is required. Outpatient ESRD services may be provided for only part of a month due to inpatient hospitalization or initiation of the services after the first of the month. The physician establishes the dialyzing cycle, performs outpatient evaluation and management services related to the dialysis services, and provides oversight and management of the patient during the dialysis as well as telephone follow-up as needed. The physician examines the patient on a routine basis for existing and potential medical problems. The patient is seen as needed when new symptoms or problems develop. The physician ensures that dialysis services are being provided as prescribed and makes adjustments to the dialysis prescription as needed. The physician monitors the patient's weight, makes recommendations regarding the patient's diet and fluid intake, and prescribes special renal supplement formula as needed. Laboratory data are reviewed. Medications and nutritional supplements are monitored and changes are made as needed. The physician also establishes, monitors, and coordinates care, which may include social service interventions, nutritional support, kidney transplant planning, and services provided by other medical and/or surgical specialists. For younger patients, the physician initiates the necessary interventions for delays in growth or development, which may include injection of growth hormones. Social development is monitored and any behavioral or school problems are addressed by making referrals and intervening as needed. The physician counsels the parents and/or caregivers and responds to questions and concerns.
The following CPT codes represent monthly End Stage Renal Disease (ESRD)-related services, also known as dialysis management services and monthly capitation payment (MCP) services. Submit the appropriate code based on the number of direct patient care services furnished by a physician or qualified practitioner. Use the CPT code appropriate for the patient’s age and number of face-to-face visits.
CPT Codes
Outpatient: 90951–90962 (in-facility, full month)
Home: 90963–90966 (home dialysis, full month)
90967-90970 (home dialysis, partial month)
These ESRD services are age-specific and reported on a daily basis. Code 90967 is for patients younger than 2; code 90968 is for patients aged 2-11; code 90969 is for patients 12-19 years of age; and code 90970 is for patients aged 20 or older.
Physician services providers should submit claims with CPT (Current Procedural Terminology) procedure codes 90951-90970 for professional ESRD (end-stage renal disease)-related services. These services may be reimbursed once per calendar month.
Dialysis Treatment Provided Outside the Member's Home
Providers should submit claims with procedure codes 90951-90962 for ESRD members who are receiving dialysis treatment somewhere other than in their homes. Providers should indicate the appropriate procedure code based on the age of the member and the number of face-to-face visits per month. The visits may occur in the physician's office, an outpatient hospital or other outpatient setting, the member's home, and the dialysis facility. If the visits occur in multiple locations, providers should indicate on claims the POS (place of service) code where most of the visits occurred.
If an ESRD member is hospitalized during the month, the physician may submit a claim with the code that reflects the appropriate number of face-to-face visits that occurred during the month on days when the member was not in the hospital.
Date of Service
Submit the claim after the end of the month coding the date of service as follows.
Indicate the first DOS of the month and always indicate a quantity of "1.0" to represent a month of care. Do not report the specific dates of each dialysis session on the claim.
Frequency Limitation
Only one MCP service in CPT range 90951–90966 is permitted per calendar month, even if multiple physicians are involved in the patient’s care.
ESRD-related Services for Less Than a Month
To submit for less than a month of ESRD/dialysis management care, use CPT code 90967–90970, based on the patient’s age and utilize the From/To Date of Service and Days/Units fields to reflect the number of visits.
Home Dialysis
Providers should submit claims with procedure codes 90963-90966 for home dialysis ESRD members. The procedure codes differ according to age, but do not specify the frequency of required visits per month.
When submitting claims for these procedure codes, report the first DOS of the month and always indicate a quantity of "1.0" to represent a month of care. Do not report the specific dates of each dialysis session.
The physician or practitioner should bill for the age-appropriate home dialysis MCP service for home dialysis if the MCP practitioner provides the following services:
A complete monthly assessment of the ESRD beneficiary
At least one face-to-face patient visit during the month
example, if a home dialysis patient was hospitalized during the month and at least one face-to-face outpatient visit and a complete monthly assessment were furnished, the MCP practitioner should bill for the full home dialysis MCP service.
The first month the beneficiary begins dialysis treatments, report the dates of service as the first date dialysis began through the end of the calendar month.
Monthly ESRD MCP claims for 90963-90966 reporting only the last day of the month as the date of service.
The Centers for Medicare & Medicaid Services (CMS) Publication 100-04, Claims Processing Manual, Chapter 8, Section 140.3 states: "Element 24A must show the dates of service during the month that are included in the MCP. The period includes the full calendar month the MCP physician/practitioner was responsible for the beneficiary's ESRD-related care."
Reporting the dates of service to span the entire month allows other services, included or not included in the MCP, to process correctly.
Home Dialysis Members Who Are Hospitalized
Procedure codes 90967-90970 are for home dialysis ESRD members who are hospitalized during the month.
These procedure codes can be used to report daily management for the days the member is not in the hospital. For example, if a home dialysis member is in the hospital for 10 days and is cared for at home the other 20 days during the month, then 20 units of one of the codes would be used. If a home dialysis member receives dialysis in a dialysis center or other facility during the month, the physician is still reimbursed for the management fee and may not be reimbursed for procedure codes 90951-90962.
Hospice Claims
Professional claims shall presume that hospice benefits are not involved unless a GV or GW modifier is appended to the claim. Claims submitted without either the GV or GW modifier will deny when patients are enrolled in hospice.
Claims will deny for all other services related to the terminal illness furnished by individuals or entities other than the designated attending physician, who may be a nurse practitioner. These claims include bills for any DME, supplies or independently practicing speech-language pathologists or physical therapists that are related to the terminal condition. These services are included in the hospice rate and paid through the institutional claim.
Related Services
If a physician other than the MCP physician provides medically necessary services (e.g., test interpretations) that would normally be included or bundled into the MCP, Medicare can make separate payment for the related services. However, Medicare considers these circumstances to be rare.
https://www.cgsmedicare.com/partb/mr/pdf/esrd.pdf
- The medical record must contain a record of the complete assessment and be available upon request
- The plan of care must be established (for new patients) or updated as needed (for established patients)
- NPPs are permitted to perform these services based on their scope of practice, as defined by state law
End-stage renal disease (ESRD) services are provided per day in an outpatient setting when less than a full month of service is required. Outpatient ESRD services may be provided for only part of a month due to inpatient hospitalization or initiation of the services after the first of the month. The physician establishes the dialyzing cycle, performs outpatient evaluation and management services related to the dialysis services, and provides oversight and management of the patient during the dialysis as well as telephone follow-up as needed. The physician examines the patient on a routine basis for existing and potential medical problems. The patient is seen as needed when new symptoms or problems develop. The physician ensures that dialysis services are being provided as prescribed and makes adjustments to the dialysis prescription as needed. The physician monitors the patient's weight, makes recommendations regarding the patient's diet and fluid intake, and prescribes special renal supplement formula as needed. Laboratory data are reviewed. Medications and nutritional supplements are monitored and changes are made as needed. The physician also establishes, monitors, and coordinates care, which may include social service interventions, nutritional support, kidney transplant planning, and services provided by other medical and/or surgical specialists. For younger patients, the physician initiates the necessary interventions for delays in growth or development, which may include injection of growth hormones. Social development is monitored and any behavioral or school problems are addressed by making referrals and intervening as needed. The physician counsels the parents and/or caregivers and responds to questions and concerns.
The following CPT codes represent monthly End Stage Renal Disease (ESRD)-related services, also known as dialysis management services and monthly capitation payment (MCP) services. Submit the appropriate code based on the number of direct patient care services furnished by a physician or qualified practitioner. Use the CPT code appropriate for the patient’s age and number of face-to-face visits.
CPT Codes
Outpatient: 90951–90962 (in-facility, full month)
Home: 90963–90966 (home dialysis, full month)
90967-90970 (home dialysis, partial month)
These ESRD services are age-specific and reported on a daily basis. Code 90967 is for patients younger than 2; code 90968 is for patients aged 2-11; code 90969 is for patients 12-19 years of age; and code 90970 is for patients aged 20 or older.
Physician services providers should submit claims with CPT (Current Procedural Terminology) procedure codes 90951-90970 for professional ESRD (end-stage renal disease)-related services. These services may be reimbursed once per calendar month.
Dialysis Treatment Provided Outside the Member's Home
Providers should submit claims with procedure codes 90951-90962 for ESRD members who are receiving dialysis treatment somewhere other than in their homes. Providers should indicate the appropriate procedure code based on the age of the member and the number of face-to-face visits per month. The visits may occur in the physician's office, an outpatient hospital or other outpatient setting, the member's home, and the dialysis facility. If the visits occur in multiple locations, providers should indicate on claims the POS (place of service) code where most of the visits occurred.
If an ESRD member is hospitalized during the month, the physician may submit a claim with the code that reflects the appropriate number of face-to-face visits that occurred during the month on days when the member was not in the hospital.
Date of Service
Submit the claim after the end of the month coding the date of service as follows.
- For the first calendar month the patient begins dialysis treatments, submit a date of service span on one detail line consisting of the first date the dialysis treatments begin through the last date of the same calendar month. Days/Units should be submitted as "1."
- For subsequent months when a full calendar month of care is provided, submit a date of service span on one detail line consisting of the first date of the calendar month and the last date of the same calendar month. Days/Units should be submitted as "1."
Indicate the first DOS of the month and always indicate a quantity of "1.0" to represent a month of care. Do not report the specific dates of each dialysis session on the claim.
Frequency Limitation
Only one MCP service in CPT range 90951–90966 is permitted per calendar month, even if multiple physicians are involved in the patient’s care.
ESRD-related Services for Less Than a Month
To submit for less than a month of ESRD/dialysis management care, use CPT code 90967–90970, based on the patient’s age and utilize the From/To Date of Service and Days/Units fields to reflect the number of visits.
Home Dialysis
Providers should submit claims with procedure codes 90963-90966 for home dialysis ESRD members. The procedure codes differ according to age, but do not specify the frequency of required visits per month.
When submitting claims for these procedure codes, report the first DOS of the month and always indicate a quantity of "1.0" to represent a month of care. Do not report the specific dates of each dialysis session.
The physician or practitioner should bill for the age-appropriate home dialysis MCP service for home dialysis if the MCP practitioner provides the following services:
A complete monthly assessment of the ESRD beneficiary
At least one face-to-face patient visit during the month
example, if a home dialysis patient was hospitalized during the month and at least one face-to-face outpatient visit and a complete monthly assessment were furnished, the MCP practitioner should bill for the full home dialysis MCP service.
The first month the beneficiary begins dialysis treatments, report the dates of service as the first date dialysis began through the end of the calendar month.
Monthly ESRD MCP claims for 90963-90966 reporting only the last day of the month as the date of service.
The Centers for Medicare & Medicaid Services (CMS) Publication 100-04, Claims Processing Manual, Chapter 8, Section 140.3 states: "Element 24A must show the dates of service during the month that are included in the MCP. The period includes the full calendar month the MCP physician/practitioner was responsible for the beneficiary's ESRD-related care."
Reporting the dates of service to span the entire month allows other services, included or not included in the MCP, to process correctly.
Home Dialysis Members Who Are Hospitalized
Procedure codes 90967-90970 are for home dialysis ESRD members who are hospitalized during the month.
These procedure codes can be used to report daily management for the days the member is not in the hospital. For example, if a home dialysis member is in the hospital for 10 days and is cared for at home the other 20 days during the month, then 20 units of one of the codes would be used. If a home dialysis member receives dialysis in a dialysis center or other facility during the month, the physician is still reimbursed for the management fee and may not be reimbursed for procedure codes 90951-90962.
Hospice Claims
Professional claims shall presume that hospice benefits are not involved unless a GV or GW modifier is appended to the claim. Claims submitted without either the GV or GW modifier will deny when patients are enrolled in hospice.
Claims will deny for all other services related to the terminal illness furnished by individuals or entities other than the designated attending physician, who may be a nurse practitioner. These claims include bills for any DME, supplies or independently practicing speech-language pathologists or physical therapists that are related to the terminal condition. These services are included in the hospice rate and paid through the institutional claim.
Related Services
If a physician other than the MCP physician provides medically necessary services (e.g., test interpretations) that would normally be included or bundled into the MCP, Medicare can make separate payment for the related services. However, Medicare considers these circumstances to be rare.
https://www.cgsmedicare.com/partb/mr/pdf/esrd.pdf