Specialty billing
Nephrology Medical Billing Services
Nephrology billing is structured around monthly capitation for dialysis patients, where a single code covers a calendar month of care and its value depends on the number of documented face-to-face visits and the patient's age. Missing a required visit reduces the entire month's payment.
Nephrology benchmarks
- Typical denial rate
- 10–16%
- Days in AR
- 35–48
- Achievable clean claim rate
- 96%+
Typical ranges for nephrology practices. Your actual numbers are measured during the audit.
The complexity
Why nephrology is uniquely difficult to bill
ESRD care bills as a monthly capitated payment, not per encounter
Payment tier depends on documented face-to-face visits within the calendar month
Home dialysis and in-center dialysis use different code families
Partial months from admission, transplant or death require prorated codes
Vascular access procedures bill separately from the monthly capitation
Non-ESRD chronic kidney disease bills as standard evaluation and management
Coding
Nephrology procedure codes we work with daily
A representative sample, not an exhaustive list. Coders are assigned by specialty rather than pooled.
| Code | Description |
|---|---|
| 90960 | ESRD services, four or more visits per month, patient 20 years or older |
| 90961 | ESRD services, two to three visits per month, patient 20 years or older |
| 90962 | ESRD services, one visit per month, patient 20 years or older |
| 90966 | ESRD services for home dialysis, full month, patient 20 years or older |
| 36901 | Introduction of needles into dialysis circuit with imaging |
| 90935 | Hemodialysis procedure with single physician evaluation |
Revenue leakage
Where nephrology practices lose money
These are the denial patterns specific to this specialty — the ones a general-purpose billing service will not be looking for.
Visit count not documented
Higher-tier monthly capitation billed without documentation of the required number of face-to-face visits.
Partial month handling
Full-month codes billed where the patient started, transferred or died mid-month, requiring per-diem codes instead.
Overlapping provider claims
Two nephrologists billing monthly capitation for the same patient in the same month.
Home versus in-center mismatch
In-center codes billed for home dialysis patients or the reverse.
Access procedure bundling
Vascular access procedures billed in ways that conflict with the monthly capitated service.
Payer landscape
What nephrology practices need to know about payers
Payer policy drives more nephrology denials than coding does. Knowing the policy before the service is what prevents them.
- ESRD monthly capitation is tiered by documented face-to-face visit count — documentation directly determines the payment tier.
- Only one physician may bill the monthly capitation per patient per month, requiring coordination in group and covering arrangements.
- Partial months require per-diem codes rather than a prorated full-month claim.
Questions
Nephrology billing FAQ
Last updated August 20, 2026
Reviewed by a certified coding leadA single code covers a full calendar month of dialysis-related physician care. Its value depends on the number of documented face-to-face visits during that month and the patient's age — four or more visits pays the highest tier, one visit the lowest. The visits must be documented individually even though only one code is billed.
The full-month code no longer applies. Per-diem codes are used for the days the patient was under care, covering admissions, transplants, transfers and deaths. Billing a full-month code for a partial month is a common error that produces both denials and audit exposure.
Only one may bill the monthly capitation per patient per month. In group practices and covering arrangements this requires explicit coordination, since duplicate submissions deny and can require refunding a paid claim. Tracking assignment per patient per month is the practical control.
Separately from the monthly capitation, since they are distinct procedural services rather than routine dialysis-related care. Imaging performed as part of the access procedure is generally included in the procedure code rather than separately billable.
Primary sources
Coverage, rates and local policy for nephrology, at the source.
- Medicare Benefit Policy Manual (opens in a new tab)
Centers for Medicare & Medicaid Services — What Medicare covers and under what conditions, as distinct from how a claim is processed. The starting point for any coverage or medical necessity question.
- Medicare Physician Fee Schedule lookup (opens in a new tab)
Centers for Medicare & Medicaid Services — Official allowed amounts by CPT/HCPCS code and locality. The reference point most commercial contracts are written against as a percentage.
- Medicare Coverage Database (LCD/NCD) (opens in a new tab)
Centers for Medicare & Medicaid Services — Searchable national and local coverage determinations. The direct answer to whether a diagnosis supports medical necessity for a given procedure.
Reading
Nephrology billing, in depth
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