Nephrology billing is unlike any other specialty in medicine. The End Stage Renal Disease (ESRD) monthly capitation payment system — where Medicare pays a single monthly fee covering all ESRD-related physician services — requires a completely different billing mindset than fee-for-service billing. Practices that do not understand this system consistently leave thousands of dollars uncollected or overcollect and face audit risk.

This guide covers the complete ESRD capitation billing framework, acute dialysis codes, partial month billing rules, and the documentation requirements that are the number one audit finding in nephrology.

What Is the ESRD Monthly Capitation Payment System?

Under the Medicare ESRD program, physicians who manage dialysis patients are paid a single monthly capitation payment (MCP) that covers all ESRD-related services provided during that calendar month — regardless of how many times the physician visits the patient or how many phone calls and care coordination activities occur.

The MCP amount varies based on two factors: the patient's age and the number of face-to-face visits the physician personally performed during the month. More visits = a higher monthly payment. This is why accurate documentation of every face-to-face visit is the most critical element of nephrology billing compliance.

ESRD Monthly Capitation CPT Codes

Adult Patients (Age 20 and Older)

• 90960 — ESRD-related services, full month, age 20+, with 4 or more face-to-face visits per month — highest payment tier
• 90961 — ESRD-related services, full month, age 20+, with 2–3 face-to-face visits per month
• 90962 — ESRD-related services, full month, age 20+, with 1 face-to-face visit per month — lowest adult payment tier

Adolescent Patients (Age 12–19)

• 90957 — ESRD-related services, full month, age 12–19, with 4 or more face-to-face visits
• 90958 — ESRD-related services, full month, age 12–19, with 2–3 face-to-face visits
• 90959 — ESRD-related services, full month, age 12–19, with 1 face-to-face visit

Child Patients (Age 2–11)

• 90954 — ESRD-related services, full month, age 2–11, with 4 or more face-to-face visits
• 90955 — ESRD-related services, full month, age 2–11, with 2–3 face-to-face visits
• 90956 — ESRD-related services, full month, age 2–11, with 1 face-to-face visit

Infant Patients (Under Age 2)

• 90951 — ESRD-related services, full month, under age 2, with 4 or more face-to-face visits
• 90952 — ESRD-related services, full month, under age 2, with 2–3 face-to-face visits
• 90953 — ESRD-related services, full month, under age 2, with 1 face-to-face visit

Home Dialysis Patients

• 90963 — ESRD-related services for home dialysis, full month, under age 2
• 90964 — ESRD-related services for home dialysis, full month, age 2–11
• 90965 — ESRD-related services for home dialysis, full month, age 12–19
• 90966 — ESRD-related services for home dialysis, full month, age 20 and older

Partial Month ESRD Billing

A full monthly capitation code can only be billed when the physician managed the patient's ESRD care for the entire calendar month. When care begins or ends mid-month — due to a new patient, hospitalization exceeding the entire month, transfer to another physician, kidney transplant, or patient death — per-day codes must be used instead.

Acute Dialysis CPT Codes

These codes are used when a physician provides dialysis for acute kidney injury — NOT for chronic ESRD patients on the capitation system. Using acute dialysis codes for ESRD patients is a billing error.

• 90935 — Hemodialysis procedure with single evaluation by physician or other qualified health professional
• 90937 — Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription
• 90940 — Hemodialysis access flow study to determine blood flow in grafts and arteriovenous fistulae
• 90945 — Dialysis procedure other than hemodialysis (e.g., peritoneal dialysis, hemofiltration) with single evaluation
• 90947 — Dialysis procedure other than hemodialysis — requiring repeated evaluations

Non-ESRD Nephrology Office Visits

Not all nephrology patients are on dialysis. Patients with Chronic Kidney Disease (CKD) stages 1–4, nephrotic syndrome, hypertensive nephropathy, and other renal conditions are billed using standard E/M codes under the 2021 AMA guidelines — based on MDM or total time.

• 99213 — Low complexity MDM or 20–29 minutes (e.g., routine CKD stage 2 follow-up, stable labs)
• 99214 — Moderate complexity MDM or 30–39 minutes (e.g., CKD stage 3–4 with medication adjustment, uncontrolled hypertension)
• 99215 — High complexity MDM or 40–54 minutes (e.g., CKD stage 5 approaching dialysis threshold, multiple comorbidities, high-risk drug management)

Top Nephrology Billing Errors

• Billing 90960 (4+ visits tier) when documentation only supports 2–3 face-to-face visits — the most common nephrology audit finding
• Billing full-month codes when the patient was hospitalized for part of the month — should use partial-month per-day codes for hospitalized days
• Using acute dialysis codes (90935/90937) for ESRD patients who should be billed under the monthly capitation system
• Billing the monthly capitation code and also separately billing individual E/M codes for ESRD-related visits — ESRD-related E/Ms are included in the MCP
• Failing to document the exact date of each face-to-face visit — verbal attestation is not sufficient for audit defense
• Missing ESRD Quality Incentive Program (QIP) reporting requirements which can affect payment adjustments
• Not billing non-ESRD conditions separately — conditions unrelated to kidney disease should be billed with standard E/M codes in addition to the MCP

Frequently Asked Questions