Specialty
Nephrology billing services
Nephrology billing services turn a month of dialysis care into one correct claim per patient: the monthly ESRD code chosen by the patient's age at the end of the month and the number of face-to-face visits, the home dialysis code when the patient dialyzed at home, per-day codes only when the month was cut short, and the 30-month window in which an employer plan pays before Medicare.
See where claims are getting stuck. No patient data needed.
Inpatient dialysis, access studies and kidney disease education each follow rules of their own. Remitwright gives nephrology practices a dedicated biller who counts the visits before the month is billed and works denials to the cause.
Nephrology billing is one of Remitwright's specialty billing services, each set out with its own code families, denial reasons and payer rules.
Last reviewed by the Remitwright billing team. Editorial policy
- 90935
- 90951-90962
- 90963-90966
Denials
Why nephrology claims get denied
The reasons that come up most on nephrology remittances, with the usual cause and the fix. Code explanations are our own; the official list is maintained by X12.
| Code | Reason | Usual cause | The fix |
|---|---|---|---|
| CO-24 | Already paid in the monthly capitation | An access study or other test interpretation billed by the same physician who bills the monthly ESRD service for that patient | Readings by the monthly physician kept off the claim, and readings by another physician billed with modifier 26 |
| CO-97 | Second monthly ESRD line for the patient | Two monthly codes for one patient and month, from two physicians in the same group or a correction sent as a new claim, which recovery auditors check automatically | One monthly line per patient per month, billed by the physician who did the complete assessment and set the plan of care |
| CO-58 | Not payable in this place of service | A dialysis procedure code billed by the physician for an ESRD patient dialyzing as an outpatient, where the monthly code already pays for the physician's renal care | Dialysis procedure codes kept to inpatient stays and to outpatient dialysis of patients without ESRD, such as acute kidney injury |
| CO-150 | Visit level not supported | The four-or-more visit code billed when the record shows three face-to-face visits, or video visits counted in a month with no in-person exam of the access | Visits counted from signed notes before the month is billed, with the in-person access exam confirmed |
| CO-167 | Diagnosis not covered for the service | Kidney disease education billed for a patient whose claim does not carry stage IV chronic kidney disease | The stage checked against the referral and the problem list before the first session is scheduled |
| CO-22 | Another plan pays first | A patient inside the 30-month coordination period with employer or union coverage billed to Medicare as primary | Coverage questions asked at the start of dialysis, with each patient's coordination period end date tracked |
Codes
Common nephrology codes and modifiers
Code families by number with our own one-line explanations. CPT descriptors belong to the AMA and are not reproduced here.
| Codes | What the family covers |
|---|---|
| 90935, 90937, 90945, 90947 | Hemodialysis, and dialysis other than hemodialysis, each with a single evaluation or with repeated evaluations, one session a day. For a patient with ESRD, Medicare pays the physician for these only on inpatient claims, and renal-related visits that day are inside them. |
| 90951-90962 | Monthly ESRD-related services for a patient who dialyzes in a center, set by age band (under 2, 2 to 11, 12 to 19, 20 and over) and by face-to-face visits in the month: four or more, two or three, or one. Billed once a month, after the month is over. |
| 90963-90966 | The full-month code for a patient who dialyzes at home, by age band: one monthly rate whatever the visit count, with at least one face-to-face visit in the month. It is also the code for a month in which the patient moved between home and center dialysis. |
| 90967-90970 | ESRD-related services by the day, by age band, with days as units: a home patient's partial month, a patient dialyzing away from home, a month cut short by admission, transplant or death before a complete assessment, and a permanent change of physician during the month. |
| 93990 | Noninvasive vascular study of a hemodialysis access. Its professional component is part of the monthly payment when the monthly physician reads it, and a study used only to monitor a working access is not covered on its own. |
| G0420, G0421 | Kidney disease education for stage IV chronic kidney disease, individual or group, on referral from the physician managing the kidney condition. Up to six one-hour sessions in a lifetime, at least 31 minutes to count as a session, with N18.4 as the diagnosis. |
| G0491 | Dialysis for acute kidney injury in a certified ESRD facility, billed by the facility on type of bill 072X with condition code 84, not on the practice's professional claim. |
Modifiers and claim codes that matter
- 25
- A visit on a dialysis day for a problem unrelated to the dialysis or the kidney failure, from the visit types Medicare allows with dialysis, and only when it is significant and separately identifiable.
- 26
- The professional component of an access study or other test read by a physician other than the one billing the monthly ESRD service. The monthly physician's own reading is already paid in the monthly code.
- Days as units on per-day codes
- The number of days the physician was responsible for the patient's outpatient ESRD care that month, with separate lines for days that are not continuous and a separate claim when the stretch runs into the next month.
- Service date span on the monthly line
- The calendar month the physician was responsible for, or from the first dialysis date to the month's end in the patient's first month, with the dialysis facility's name, address and NPI in item 32.
Payers
Payer notes
- MedicareThe monthly ESRD payment for center patients rises with the visits made in the month, from one visit to two or three to four or more, and is billed once a month after the month ends at 80 percent of the approved amount once the Part B deductible is met. The patient's age at the end of the month sets the age band, and the physician who did the complete assessment and set the plan of care bills it, even when other physicians or NPPs in the same group made some of the visits.1
- MedicareA home dialysis patient is paid at one monthly rate by age, with at least one face-to-face visit in the month that the contractor may waive case by case. A home patient who dialyzes in a center during the month, or who switches between home and center, is still billed on the home code.1
- MedicareVisits under the two-to-three and four-or-more monthly codes may be furnished by interactive audio and video, but at least one visit a month has to be hands-on, with an examination of the vascular access by a physician, clinical nurse specialist, nurse practitioner or physician assistant.2
- MedicareESRD coverage usually starts on the first day of the fourth month of dialysis, and as early as the first month for a patient in a home dialysis training program during the first three months. With employer or union coverage, the employer plan pays first for a 30-month coordination period. Coverage ends 12 months after dialysis stops or 36 months after a transplant.5
- MedicareKidney disease education is limited to six sessions in a lifetime, and sessions beyond six are denied as over the benefit maximum. A renal dialysis facility cannot bill it, and a professional and an institutional claim for it on the same date are not both allowed.6
- MedicareAn approved recovery audit topic reviews 90957 to 90962 automatically: the line with a single paid unit of 90957 or 90960 is treated as the covered service, and any other monthly lines for the same period are recovered in full.7
Authorizations
Nephrology claims to Original Medicare turn on the monthly assessment, the visit count and the dates rather than on an authorization number: one monthly code per patient, the right age band and visit level, and per-day codes only in the cases Medicare lists. Medicare Advantage and commercial plans set their own rules for dialysis-related services, access procedures, imaging and infused drugs, and an employer plan that is primary during the ESRD coordination period applies its own requirements first. Your biller keeps those rules by payer, confirms who is primary each month, and requests any authorization a plan asks for before the service.
Documentation traps
- Visit notes that do not say whether the visit was in person or by video, so the month's hands-on access exam cannot be shown
- No record of the complete monthly assessment, which decides who bills the monthly code and whether the per-day codes apply
- Admission and discharge dates missing from the dialysis record, so a partial month cannot be counted
- A home dialysis month with no face-to-face visit and no note of how the patient was managed, when any waiver is decided case by case
- Kidney disease education sessions without start and end times, when a session has to run at least 31 minutes
- An access study ordered with no sign or symptom of access trouble, when a study done only to monitor a working access is not covered
What a specialist checks
Specialist or generalist for nephrology billing?
A generalist biller can enter a nephrology claim. Whether it pays turns on three things specific to nephrology billing, and a specialty-aware biller checks each one.
Code families
Each family billed with what the chart has to show for it.
- 90935, 90937, 90945, 90947
- 90951-90962
- 90963-90966
Modifiers and claim codes
Each one used only where the record supports it.
- 25
- 26
- Days as units on per-day codes
If you are moving from another billing company or an in-house biller, switching billing companies follows a plan: the old and new processes run side by side until the new one is proven, and every login and every nephrology claim stays in your name.
What we handle
What we handle for nephrology practices
- Medicare billingPart B claims, MSP, ABNs and appeals
- Eligibility verificationCoverage and benefits checked before visits
- Secondary claims billingSecondary and tertiary claims, tracked
- Charge entryEvery encounter captured, nothing left unbilled
- Denial managementEvery denial read, worked and appealed
- Payment postingERAs and EOBs posted, variances flagged
A dedicated biller with named cover, working inside your system and reporting to you on one written page. How it works sets out the five stages.
Worked example: the month with a hospital stay
A 64-year-old patient dialyzes in a center. The nephrologist does a full assessment with a face-to-face visit on the 3rd, the patient is admitted from the 10th to the 20th and is seen once by the nephrologist in the hospital, and the nephrologist sees the patient again in the unit on the 25th. The practice system sees the admission and bills a per-day code for 20 days.
The biller reads the month again. A complete assessment was done, so the month belongs on the monthly code for two or three visits in the 20-and-over band, 90961, not on per-day codes. The inpatient renal visit goes on its own inpatient visit code and is not counted toward the monthly visits. The per-day claim is corrected, and the charge review now looks for a complete assessment before any per-day code is used.
Software
Systems nephrology practices usually run
Your biller works inside your system as a user you create. All the systems we work in.
Questions
Questions about nephrology billing
How do we pick the monthly ESRD code?
When are the per-day ESRD codes used?
Can monthly ESRD visits be done by telehealth?
Who bills the monthly code when several clinicians see the patient?
Why was our dialysis procedure code denied for an outpatient?
When does Medicare start paying for a new dialysis patient?
How many kidney disease education sessions can we bill?
What does a nephrology practice give its biller to start?
Next step
See where your nephrology claims are getting stuck.
Three quick questions. No patient data. A billing specialist reads every request and replies in writing.
- Three questions, about two minutes
- No patient data, no software to buy
- A written reply from a biller, not a sales deck
You answer three questions
A billing specialist reads them
A written reply by email
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- A billing specialist reads your answers and replies by email.
- If a look at real claims makes sense, we agree read-only access under a BAA first.
- You get a written summary of what is worth working and what it would take. No commitment.
While you wait: see the sample weekly report or read how switching works. You can also download the sample weekly report (PDF).