Nephrology Billing Services
Nephrology runs on a payment split that exists nowhere else in medicine, and confusing the two sides is the most expensive mistake a dialysis practice makes. The nephrologist's side is the monthly capitation payment: one payment per ESRD patient per month covering that physician's professional services, at an amount set by the patient's age band and the face-to-face visits the chart can actually prove. The facility's side is separate: the dialysis unit bills its own treatment claim, and the regulation pays the physician's administrative services to the facility inside the facility's rate, not to the nephrologist. Between the top and bottom visit tier for an adult sits $157.65 per patient per month, and the exposure runs both ways — a tier claimed without the notes behind it is downcoded on audit, and a tier under-claimed when the visits did happen is work performed and never billed. Neither error is visible from the claim file. We take that reconciliation on. Each month, before the claim goes out, we compare the facility's treatment log and the physician's rounding record against the dated encounter notes in the chart, patient by patient, code the tier the documentation supports, and apply the proportional reduction for days a patient was hospitalized or not attended. We confirm each plan's billing model against its own published policy when a patient joins the panel, because commercial and Medicare Advantage plans are not bound to the capitation method and some require per-visit billing. And we bill the work outside the capitation on its own documentation: dialysis-circuit access procedures on their own operative note at the right place of service, kidney biopsy with its imaging guidance, and the transplant evaluation and post-transplant visits that get written off as the transplant center's. It is built for nephrology groups running in-center and home dialysis panels, CKD clinics, and transplant follow-up across Medicare and commercial books.
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What does nephrology and dialysis billing cover?
On a dialysis panel the monthly capitation payment is the nephrologist's whole month, while the facility bills its own treatment claim, under 42 CFR 414.314. The tier is set by the patient's age band and the documented face-to-face visit count, so before the claim goes out we count the dated encounter notes against the tier — in both directions — and apply the proportional reduction for days the patient was hospitalized or not attended. Vascular access and other surgical work sit outside the capitation, and we bill it on its own operative note.
- Monthly capitation coded to the tier the documented visits support — 90951–90962 in-center, 90963–90966 home, 90967–90970 for a partial month
- Professional and facility sides kept apart: the MCP is the nephrologist's payment, the dialysis facility bills its own treatment claim
- Visit-count reconciliation before the month closes, with a dated encounter note behind every visit the tier claims
- Vascular access billed outside the MCP on its own operative note, on the current 36901–36909 dialysis-circuit family
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Who This Page Is For
Common Billing Friction in Nephrology
MCP tier selection, and the visit-count reconciliation that has to run both ways
On the CY2026 Medicare physician fee schedule the adult tiers are 90960 at $372.75 for four or more face-to-face visits in the month, 90961 at $310.63 for two or three, and 90962 at $215.10 for one — national unadjusted amounts, before locality adjustment, and not what a commercial contract pays. The in-center series runs by age band — 90951–90953 under 2 years, 90954–90956 for 2–11, 90957–90959 for 12–19 and 90960–90962 for 20 and over — and inside each band the first code is the four-or-more-visit tier, the second 2–3 visits and the third a single visit, so the tier is the code's position in its band rather than its last digit. Every face-to-face visit behind the tier needs its own dated encounter note describing the assessment performed. The exposure runs in both directions: billing 90960 without four documented visits is downcoded on audit, and billing 90962 when four visits happened but only one was written up gives away $157.65 for that patient that month. Neither error is visible from the claim file. The reconciliation that finds both compares the facility's treatment log and the physician's rounding record against the dated notes in the chart, patient by patient, before the month is closed — and it has to catch the months a patient was hospitalized or off the panel, because 42 CFR 414.314(b)(3) reduces the MCP in proportion to the days the patient was not attended.
Commercial and Medicare Advantage ESRD patients, and the per-payer billing model
The MCP is a Medicare payment method defined by 42 CFR 414.314. Commercial plans and Medicare Advantage plans are not bound to it, and some require per-visit E/M billing for dialysis-related encounters instead of a monthly capitation line. Submitting the wrong model produces a denial in either direction. Which model applies is a per-plan and often a per-product fact rather than an industry rule, so it has to be confirmed against that plan's own published reimbursement policy and recorded, not inferred from the payer's name. The practical control is resolving the coverage and the billing model at the point the patient joins the panel, instead of discovering it on the first denial three months later.
Vascular access sits outside the MCP — and 36147 and 36148 are no longer valid
Surgical services, including declotting of a shunt, are expressly excluded from the MCP by 42 CFR 414.314(b), so access work is separately billable when it is performed and documented on its own operative note. The codes have moved, though: 36147 and 36148 do not appear anywhere in the CY2026 Medicare physician fee schedule, and material still listing them for fistulography is quoting deleted codes. Dialysis-circuit work now runs through the 36901–36909 family, which bundles the circuit study together with whatever intervention is performed through it — 36901–36903 are the dialysis-circuit catheter introduction and intervention codes on the CY2026 fee schedule and 36904–36906 the dialysis-circuit thrombectomy codes. Because each of them bundles a specific combination of work, the code has to be selected from the descriptor against an operative note that names every segment treated and every device used, not from a house crosswalk. Place of service then moves the amount more than any other variable on this page: on the CY2026 fee schedule, national unadjusted, 36902 is $1,190.74 non-facility against $210.09 facility, and 36906 is $5,914.97 against $445.23, because the non-facility amount carries the supply and equipment cost that a hospital or ASC bills on its own claim instead. The same exclusion list also covers inpatient services the physician elects to bill separately during a hospital stay and care unrelated to the patient's renal condition, and dialysis outside the monthly capitation bills per treatment instead — 90935 and 90937 for hemodialysis with evaluation, 90945 and 90947 for other dialysis procedures, which is also how dialysis for acute kidney injury in a patient who is not on the ESRD benefit is billed.
Kidney biopsy — two codes that are not interchangeable, and the guidance billed with them
50200 is renal biopsy performed percutaneously by trocar or needle; 50205 is renal biopsy by surgical exposure of the kidney. They are separated by approach, not by whether the kidney is native or a transplant, so a percutaneous allograft biopsy is still 50200. Their global periods differ accordingly: on the CY2026 Medicare physician fee schedule 50200 carries a 000-day global and 50205 a 090-day global. Setting matters as much as approach — 50200 is $492.00 national unadjusted non-facility against $110.22 facility, because the non-facility amount carries practice expense the hospital would otherwise bill. Imaging guidance is separately reportable when performed and documented: 76942 ultrasound guidance at $64.13 global and $31.40 for the professional component, 77012 CT guidance at $122.92 and $67.14 — and the professional-component figure is the relevant one whenever the scanner belongs to the facility. Pathology on the specimen is the pathologist's claim, and 88305 is reported per specimen rather than per block.
Transplant evaluation and post-transplant management — billable, and routinely written off
Pre-transplant evaluation is multi-visit workup that bills as ordinary office E/M on the documented medical decision making or total time. Post-transplant management — immunosuppression dosing, rejection surveillance, calcineurin-inhibitor level monitoring — likewise bills as ordinary E/M; there is no special transplant management code, which is part of why the work gets treated as unbillable. A practice that assumes a transplant patient is 'covered by the transplant center' and does not bill its own management visits is simply not billing work it performed. The fix belongs at the front desk rather than in coding: a transplant patient on the nephrology schedule is this practice's billable encounter unless the note shows the visit was performed by the transplant center's team.
Nephrology-Specific Payer Issues We Watch For
Medicare
Issue: Monthly capitation codes (90951–90962 for in-center dialysis) are selected on the patient's age band and the number of face-to-face visits that month, and each visit must be supported by its own dated encounter note
Our approach: We verify face-to-face visit counts against MCP code selection for every monthly claim and downcode when documentation does not support the billed visit count
Commercial and Medicare Advantage plans
Issue: The monthly capitation method is defined for Medicare by 42 CFR 414.314; commercial and Medicare Advantage plans are not bound to it, and some require per-visit E/M billing instead. Which model applies is set in that plan's own reimbursement policy and differs by plan and product
Our approach: We confirm the billing model against the plan's published policy when the patient joins the panel and record it in a per-payer routing matrix, instead of assuming capitation and finding out on a denial
Blue Cross Blue Shield plans
Issue: Blue Cross Blue Shield plans are separately operated, so the drug policy governing erythropoiesis-stimulating agents in dialysis — the hemoglobin documentation it wants and the review pathway it uses — is set plan by plan rather than across the brand
Our approach: We verify the specific member's plan policy before the authorization goes in, submit the hemoglobin data that policy asks for, and record which plan and which policy date the requirement came from
Medicare Advantage plans
Issue: Some Medicare Advantage and commercial plans apply their own bundling policy to access procedures performed in the dialysis unit, so a separately performed access procedure can be denied as already included in the dialysis payment
Our approach: We document vascular access procedures with distinct operative notes and bill separately when performed outside the routine dialysis session with appropriate modifiers
What We Handle
MCP coding — 90951–90970 across age bands, visit tiers, home dialysis and partial months
Age-band and visit-tier MCP selection with a dated encounter note behind every visit the tier claims, the home-dialysis full-month set 90963–90966, the per-day codes 90967–90970 for a partial month, and the proportional reduction under 42 CFR 414.314(b)(3) for days the patient was hospitalized or not attended.
Per-payer billing model for commercial and Medicare Advantage ESRD patients
A routing matrix built from each plan's own published reimbursement policy recording whether it accepts monthly capitation or requires per-visit E/M, confirmed when the patient joins the panel rather than on the first denial, and re-checked when the plan reissues the policy.
Vascular access — the 36901–36909 dialysis-circuit study and intervention family
Access maintenance coded on the current dialysis-circuit family with its own operative note, billed outside the MCP under 42 CFR 414.314(b), with place of service set correctly because the non-facility and facility amounts for these codes differ by several multiples.
CKD stage-based E/M and the ESRD transition
CKD pre-dialysis E/M coding (99214/99215 for moderate-to-high MDM patients with stage 3b–5 CKD), the diagnosis-coding discipline for CKD stages (N18.30, N18.31, N18.32 for stage 3 sub-stages, N18.4 for stage 4, N18.5 for stage 5), and the transition workflow when a patient initiates dialysis.
Kidney biopsy — 50200 and 50205, with imaging guidance
Percutaneous renal biopsy (50200, 000-day global) whether the kidney is native or a transplant, and biopsy by surgical exposure (50205, 090-day global), with 76942 or 77012 imaging guidance reported separately when performed and the professional-component split applied where the equipment belongs to the facility.
Transplant evaluation, listing, and post-transplant management
Pre-transplant E/M coding for transplant evaluation and listing workup, post-transplant management coding for immunosuppression and rejection surveillance, and the longitudinal billing across the post-transplant period when nephrology continues to manage the medical side.
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Key Nephrology CPT Codes
| CPT Code | Description | Medicare Amount CY2026 national, non-facility |
|---|---|---|
| 90960 | ESRD-related services, per month, age 20 and over, 4 or more face-to-face visits | $373 |
| 90961 | ESRD-related services, per month, age 20 and over, 2–3 face-to-face visits | $311 |
| 90962 | ESRD-related services, per month, age 20 and over, 1 face-to-face visit | $215 |
| 90935 | Hemodialysis procedure with single physician evaluation | $61 |
| 90937 | Hemodialysis procedure requiring repeated evaluations | $89 |
| 90945 | Dialysis procedure other than hemodialysis, with single evaluation | $77 |
| 50360 | Renal allotransplantation, implantation of graft, excluding donor and recipient nephrectomy | $2,293 |
| 90951 | ESRD-related services, per month, under 2 years, 4 or more face-to-face visits | $1,184 |
Amounts are the Medicare national unadjusted non-facility amounts for CY2026, computed from the published CMS relative value file. They are not what a commercial payer pays, and your locality adjustment moves them. A dash means Medicare publishes no amount for that code — because it is non-covered, bundled, or priced outside the fee schedule.
Why General Billing Teams Miss Nephrology Issues
General billing staff handle dozens of specialties and rarely develop the depth needed for nephrology coding nuances. Here is what gets missed.
Modifier and bundling errors
Specialty-specific modifier rules and CCI edits are frequently overlooked by teams that do not work exclusively in nephrology.
Under-coding high-complexity visits
Nephrology encounters often qualify for higher-level E/M codes, but generalist billers default to mid-level codes to avoid audit risk.
Missed payer-specific rules
Each payer has unique coverage and documentation requirements for nephrology procedures that general teams rarely memorize.
Slow denial turnaround
Without specialty knowledge, appeal letters lack the clinical specificity needed to overturn nephrology denials quickly.
“The monthly capitation tier is decided in the chart, not on the claim. If nobody reconciles the documented visit count against the tier before the month closes, the practice is guessing in both directions — and the transplant follow-up work gets written off as somebody else's.”
MedPrecision Billing Team
Nephrology Coding and Compliance Specialist
Transition Plan
Switching billing partners should not disrupt patient care or cash flow. Our transition plan is designed for zero downtime.
Discovery and Specialty Audit
We review your current nephrology billing workflows, denial patterns, and payer mix to build a tailored onboarding plan.
System Integration
We connect to your EHR and practice management system, configure specialty-specific code sets, and validate charge capture workflows.
Parallel Billing Period
We run billing in parallel with your current process for 2-4 weeks to verify accuracy before taking over completely.
Full Transition and Reporting
Once validated, we assume full billing responsibility with monthly reporting dashboards and a dedicated account manager.
Nephrology Billing Terms
- Monthly Capitation Payment (MCP)
- Medicare's per-month payment for a nephrologist's ESRD-related professional services under 42 CFR 414.314, covering all professional services furnished that month except those the regulation lists separately. The code is chosen by the patient's age band and the number of documented face-to-face visits: 90951–90962 in-center, 90963–90966 for home dialysis, and 90967–90970 per day for a partial month.
- ESRD PPS (Prospective Payment System)
- Medicare's bundled payment system for dialysis facility services that includes a base rate adjusted for patient and facility characteristics. Covers dialysis treatment, drugs, lab tests, and supplies in a single composite payment.
- Composite Rate
- The term the ESRD regulations use for the bundled per-treatment payment to the dialysis facility. It matters on the professional side because 42 CFR 414.314(a)(5) pays the physician's administrative services to the facility as part of that rate, rather than to the nephrologist under the MCP.
- Vascular Access Management
- Procedures to create, maintain and salvage the arteriovenous fistulas, grafts and catheters used for dialysis. 42 CFR 414.314(b) places surgical services, including declotting of a shunt, outside the MCP, so this work is separately billable when it is performed and documented on its own operative note.
- Transplant Evaluation Coding
- Codes for the evaluation and management of patients being assessed for kidney transplant eligibility, including pre-transplant workup, listing management, and post-transplant follow-up care.
- EPO/ESA Administration
- Erythropoiesis-stimulating agent administration for dialysis-related anemia. Billing requires documentation of hemoglobin levels and dose adjustments, and where a commercial plan requires prior authorization, the thresholds and the review pathway are set by that plan's own drug policy rather than by a common standard.
Last updated: 2026-09-17
Common Questions
Common questions about nephrology billing services.
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Request ReviewHow does monthly capitation payment work for dialysis patients?
The MCP series is 90951–90970. For in-center dialysis, 90951–90962 pay a monthly bundled amount for the physician's ESRD-related professional services, chosen by the patient's age band and the number of documented face-to-face visits that month: inside each band the first code is the four-or-more-visit tier, the second is 2–3 visits and the third is a single visit. Home dialysis has its own full-month set at 90963–90966 by age, and 90967–90970 cover a partial month on a per-day basis. We reconcile the documented visit count against the tier each month before the claim goes out, and apply the proportional reduction under 42 CFR 414.314 for days the patient was hospitalized or not attended.
How do you bill for vascular access procedures?
Access procedures are billed on their own operative note, separately from the monthly capitation, because 42 CFR 414.314(b) puts surgical services outside the MCP. Dialysis-circuit angiography and intervention are reported from the 36901–36909 family — 36147 and 36148 were deleted and no longer appear on the Medicare physician fee schedule — while access creation and revision have their own codes. We set the place of service correctly, because the non-facility and facility amounts for these codes differ by several multiples, and apply the professional-component modifier where the imaging equipment belongs to the facility.
What changes when a CKD patient starts dialysis?
When a patient starts maintenance dialysis, the physician's billing moves from ordinary office E/M to the ESRD monthly capitation model. We handle the transition: the partial first month billed on the per-day codes 90967–90970 rather than a full-month code, the age band and visit tier set correctly from the start, and the monthly visit-count reconciliation established so the tier is supported by dated encounter notes from the first claim onward.
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