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Revenue Cycle Management
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Specialty billing Nephrology & Dialysis
Nephrology billing for dialysis and CKD practices. We match documented ESRD visits to the right monthly capitation tier before claims go out.
Nephrology focus
The Revenue Problem
Most practices we talk to recognize at least three of these the moment we say them out loud.
Monthly capitation payment billing pays based on how many face-to-face visits a patient gets each month. Miss one visit in the count, and the whole claim drops a tier. Do that across your ESRD panel, month after month, and the losses stack up fast. For patients 20 and older, 90960 (four or more visits a month) pays more than 90961 (two or three visits), so a visit that was documented but never reached the claim can drop it to the lower code.
Your nephrologist may visit a different dialysis facility each rounding day. Each dialysis facility runs its own system and its own rounding sheet. Nephrology dialysis rounding billing depends entirely on someone capturing that visit before it disappears into a facility's internal log — if it isn't captured, it doesn't exist for MCP purposes, even though the care happened.
A patient starts dialysis for acute kidney injury, not chronic kidney disease. Physician dialysis services for AKI are billed per session (90935/90937 hemodialysis, 90945/90947 other dialysis), because the monthly capitation payment is for ESRD. Using an N17 acute kidney injury code when the documentation supports a CKD stage, or the reverse, leads to denials.
CKD staging isn't one code. Stage 3 alone splits into N18.31 and N18.32 depending on eGFR, and that's before you factor in hypertensive CKD (I12/I13), diabetic CKD (E11.22), dialysis dependence (Z99.2), or transplant status (Z94.0). Get the stage or the underlying cause wrong, and the claim doesn't match the medical necessity documentation Medicare expects.
During a 30-month coordination period, an employer group health plan pays first and Medicare pays second. The clock starts in the patient's first month of ESRD-based Medicare eligibility, which is usually the fourth month of dialysis, not the day dialysis starts. This is the Medicare Secondary Payer 30-month rule for ESRD. Bill Medicare first during that window, and the claim either bounces or gets paid and clawed back later.
Home hemodialysis and home peritoneal dialysis use their own home dialysis billing codes, 90963 through 90966, plus separate nephrology telehealth billing rules. Telehealth can cover monthly ESRD visits for these patients, within limits. Medicare still requires them to be seen in person each month during their first three months on home dialysis, and at least once every three consecutive months from then on.
How We Close the Gaps
We built our nephrology revenue cycle management process around how ESRD care actually gets delivered, not around a generic dialysis billing services template.
We match your nephrologist's rounding logs against what actually got billed, facility by facility, POS 65 by POS 65. If a visit happened at Fresenius on the 14th and never made it into your system, we catch it before the claim goes out.
Each ESRD patient's visit count is checked against dated, documented encounters before the monthly capitation payment bills. We don't guess between 90960, 90961, and 90962; we confirm it.
We track each patient's 30-month coordination period individually, so the employer plan gets billed first when it should, and Medicare picks up exactly when it's supposed to.
Fistula creation (36818-36821), graft placement (36825/36830), and catheter insertion (36558), along with the broader 36901-36909 series, get coded to match the access type and approach documented in the operative note.
For ESRD patients on dialysis, ESAs (Q4081 epoetin alfa, J0882 darbepoetin alfa) are part of the facility's ESRD PPS bundle and are billed by the dialysis facility, not on the physician claim; J0885 is the non-ESRD epoetin code. Kidney Disease Education services (G0420/G0421) for stage 4 CKD patients are billed by the practice and are easy to miss, so we capture them alongside the professional claim.
Book a free consultation, and we'll talk through where visit captures may be falling short across your facilities.
Book a Free ConsultationESRD PPS & Modifiers
Dialysis billing guidelines get more complicated once you factor in how the facility side gets paid. The ESRD PPS pays dialysis facilities a single bundled rate per treatment, and ESRD PPS consolidated billing means most drugs, labs, and supplies tied to dialysis are folded into that bundle instead of billed separately.
Two modifiers cause most of the confusion. Facilities use the CG modifier to show that dialysis treatments beyond the monthly limit are medically justified.
On top of that, facilities carry ESRD QIP risk, which is a payment reduction of up to 2% for facilities that miss CMS's quality benchmarks. It doesn't hit your nephrologist's professional claim directly, but it shapes how facilities negotiate and report data, which is worth knowing if you're coordinating care across several of them.
From July 1, 2026, ESRD facilities no longer report the AX modifier on claims for the ESRD PPS add-on payments (TDAPA, TPNIES and CRA TPNIES), under Change Request 14354 and revised Claims Processing Manual ch. 8. If a facility partner is still appending AX, its billing instructions are out of date.
Source: CMS MLN MM14354.
Value-Based Kidney Care
If your practice participates in the Kidney Care Choices (KCC) Model's CKCC options, 2026 brought real changes to your reimbursement math.
The Kidney Care First track, one of the original capitated options under the Kidney Care Choices model, ended December 31, 2025, according to CMS's KCC Performance Year 2026 update. The Graduated, Professional, and Global CKCC options are still running, and CMS extended them through the end of 2027 to give practices time to adjust.
But “extended” doesn't mean “unchanged.” Starting in performance year 2026, CMS added a benchmark discount for Global and Professional risk participants, reduced the quarterly CKD capitation payment, and eliminated the transplant bonus that used to pay up to $15,000 per successful kidney transplant. Separately, the mandatory ESRD Treatment Choices (ETC) model, originally scheduled to run through June 2027, was terminated early at the end of 2025, so facility-level performance payment adjustments no longer apply the way they used to.
Your fee-for-service claims still matter under KCC, because they feed the cost and quality data your model results are built on.
FAQ
Answers on MCP tiers, home dialysis, the MSP 30-month rule and the Kidney Care Choices model. More questions? See our FAQ
It's how Medicare pays nephrologists for ESRD-related services for dialysis patients each month, instead of per visit. For in-center patients, the code depends on the patient's age and the number of face-to-face visits in the month, which is why accurate visit counts matter.
For patients 20 and older, they're visit-count tiers for the same monthly service: 90960 is four or more face-to-face visits, 90961 is two or three, and 90962 is one. Each lower tier pays less for the same patient.
Home dialysis patients are billed with 90963–90966, chosen by age, for a full month. Monthly visits can be done by telehealth, but Medicare requires an in-person visit at least monthly for the first three months of home dialysis and at least once every three consecutive months after that.
When a patient has employer group health plan coverage, that plan pays first and Medicare pays second for a 30-month coordination period. The period starts with the first month the patient is eligible for Medicare based on ESRD, usually the fourth month of dialysis. Billing Medicare first in that window leads to denials or repayment demands.
It's CMS's voluntary value-based model for patients with CKD stages 4 and 5 and ESRD. The Kidney Care First option ended December 31, 2025. The Graduated, Professional and Global CKCC options continue through 2027, with 2026 changes that include benchmark discounts, a lower CKD quarterly capitation payment and no kidney transplant bonus for transplants from 2026.
Free Consultation · No Obligation
MedixCode offers a free consultation for nephrology practices. We'll talk through MCP capture across the facilities your nephrologist covers and where visit-count tiers may be slipping. No obligation.
Prefer email? Write to info@medixcode.com about your dialysis billing.
