ESRD monthly capitation claims, payer order for dialysis patients, kidney disease education and referral growth for nephrology practices, built on CMS rules and your Medicare contractor's guidance.
Quick answer
Nephrology billing services handle the claims a kidney practice creates: monthly ESRD capitation codes chosen by age, visit count and dialysis setting, per-day codes for partial months, dialysis access procedures, CKD diagnosis coding and payer order for dialysis patients. RCM Finder pairs that billing with front-desk assistants, referral marketing and a claims portal, starting with a free audit.
For dialysis patients, Medicare pays the nephrologist through one monthly claim instead of a claim per visit. The code depends on the patient's age, the number of visits that month and whether the patient dialyzes in a center or at home.
Medicare pays these ESRD-related services through a monthly capitation payment (MCP). First Coast, a Medicare contractor, groups the codes into three sets: 90951–90962 for a full month in a facility, 90963–90966 for a full home dialysis month, and 90967–90970 for less than a full month. Noridian lists adult facility tiers of four or more visits, two or three, or one. The code is billed once a month, after the month ends, using the patient's age at month end. These rules come from Noridian and First Coast guidance; other Medicare contractors may word them differently.
Payer order is the second difference: employer coverage can make Medicare pay second for up to 30 months.
CMS's CY 2026 Physician Fee Schedule final rule fact sheet (October 31, 2025) set the conversion factor at $33.40 for clinicians who are not qualifying APM participants, up from $32.35. The CY 2027 proposed rule (July 14, 2026) proposes $32.84 for the same group; it is a proposal, so check the final rule before budgeting. CMS ended the mandatory ESRD Treatment Choices Model as of December 31, 2025. The voluntary Kidney Care Choices Model runs through 2027 for current participants.
A nephrology practice needs early referrals, a front desk that knows each patient's payer order, billing that closes every month cleanly and software that shows every claim. Each pillar handles one.
Revenue leaks at the handoffs: a fourth visit never logged, an employer plan billed second. We run all four pillars against one set of payer rules.
Our healthcare digital marketing reaches the offices that refer kidney patients and the patients searching for kidney care nearby, through local SEO, Google Ads and reputation work.
Our virtual medical assistants for nephrology run your front desk on your practice's time zone. They verify eligibility, ask about employer coverage, log dialysis and transplant dates and book the in-person visits home dialysis patients need.
Our end-to-end nephrology revenue cycle management covers coding support, claim scrubbing, denial management and A/R follow-up, with extra checks on MCP tiers, per-day units, global periods and CKD staging.
Our practice management system tracks every claim by stage. It applies specialty-aware billing logic to each claim, checks that data is complete before submission and flags payments below the expected amount.
Find where your dialysis claims leak
We review recent MCP claims, denials and visit records, then show where counts, payer order or timing cost you.
Each service family has its own counting, timing or eligibility rule. Codes are described in our own words (the AMA owns CPT descriptors); check current code sets before billing.
| Service family | Code examples (our wording) | Billing rule | Typical denial or audit trigger |
|---|---|---|---|
| In-facility dialysis, full month | 90951–90962: four age bands, each split by 4+, 2–3 or 1 visits; adults 90960, 90961, 90962 | One claim per month after it ends; age at month end; one visit includes an access exam | Claim dated before month end; visits not documented; duplicate MCP within a team |
| Home dialysis, full month | 90963–90966 by age; 90966 for adults | Complete monthly assessment and at least one face-to-face visit | Telehealth used in place of a required in-person assessment |
| Less than a full month | 90967–90970 per day, by age; 90970 for adults | Units equal dialysis days (14 home days, then hospitalized: 14 units) | Full-month code for a partial month; units not matching dialysis days |
| Dialysis procedure with evaluation | 90935 (hemodialysis); 90945 (other than hemodialysis) | A related same-day E/M by the same provider is included | Separate E/M for the same dialysis evaluation |
| Access surgery and circuit work | 36821 (direct artery-to-vein fistula); 36901 (circuit imaging); 36902 (imaging plus angioplasty) | Paid outside the MCP; each code has a global period | Global-period visits without modifier 24, 25 or 57 |
| Kidney disease education | G0420 (individual); G0421 (group); per one-hour session | Stage IV CKD; referral; up to 6 sessions | Patient not at stage IV; a seventh session; billed by a dialysis facility |
| Chronic care management | CCM codes | Two or more chronic conditions; consent before billing | CCM billed in the same service period as 90951–90970 |
| CKD diagnosis coding | N18.1–N18.5 by stage (stage 3a N18.31, 3b N18.32); N18.6 (ESRD); N18.9 (unspecified) | Code the documented stage; when diabetes or hypertension is linked, follow the N18 sequencing notes in the current tabular; record transplant status | Unspecified stage when the note states one; linked diabetes or hypertension left uncoded |
Sources: Noridian MCP and the Medical Record (2025); First Coast ESRD MCP claims (2026); eCFR 42 CFR 414.314 and 410.48 (2026); CMS NCCI Policy Manual ch. XI (2026); CMS MLN Global Surgery booklet (2025) and CCM booklet MLN909188 (2025); CDC ICD-10-CM 2021 tabular addenda and FY 2027 ICD-10-CM guidelines; ICD10Data (secondary) for the N18 list; AAPC code summaries and an Iowa HHS code table for plain-language code meanings. MCP rules come from Medicare contractor guidance and vary by contractor and payer.
Noridian says to bill the first dialysis month from the first treatment through month end, and later months as the full calendar month. A partner or employee in the same group can furnish some visits, but the billing practitioner performs the complete assessment and sets the plan of care. Its ESRD documentation list includes dialysis treatment sheets.
First Coast says to bill a full home dialysis month when the practitioner provides a complete monthly assessment and at least one face-to-face visit, even if the patient was hospitalized. After 14 home dialysis days and a hospital stay for the rest of the month, the age-appropriate per-day code is billed with 14 units. Other Medicare contractors may word these rules differently.
Access surgery and circuit interventions are billed outside the MCP, and each code carries its own global period. CMS's Global Surgery booklet (December 2025) defines 0-, 10- and 90-day periods and the modifiers for work inside them: 24 for an unrelated visit, 25 for a separate same-day visit, 57 for the decision for major surgery, and 58, 78 or 79 for later procedures. Check each code's global indicator before billing a follow-up visit.
ICD-10-CM codes chronic kidney disease by stage, from N18.1 to N18.6; since 2021, stage 3 has separate 3a and 3b codes (N18.31, N18.32). The FY 2027 official coding guidelines presume a link between conditions joined by 'with' in the classification, so documented diabetes or hypertension changes how CKD is coded; follow the N18 sequencing notes in the current tabular. Diagnoses also feed risk adjustment: CMS's Medicare Managed Care Manual, chapter 7 (2014 revision) uses diagnoses from documented face-to-face visits and runs a separate ESRD model. See our HCC coding guide, diabetic HCC coding guide and chronic care management billing guide. Our endocrinology billing page covers the diabetes side.
Under 42 CFR 406.13, ESRD-only Medicare ends after the 36th month following the transplant month. Since January 1, 2023, people who lose it may enroll in Part B for immunosuppressive drug coverage only.
This page covers professional claims. Under chapter 8 of the Medicare Claims Processing Manual, facilities bill on the institutional claim (type of bill 72X), and the ESRD payment system has included the drugs and biologicals used to treat ESRD since January 1, 2011. Noridian requires the KX modifier for sessions above the monthly maximum.
Check who pays first before the first dialysis claim, not after a denial: the Medicare start date, employer coverage, transplant dates and plan authorization rules.
Under 42 CFR 406.13, ESRD-based Medicare usually starts on the first day of the third month after dialysis begins: a January start means April 1 coverage. Self-dialysis training or a transplant admission can move it earlier.
CMS's Medicare Secondary Payer Manual, chapter 2 makes Medicare secondary to group health plan coverage for up to 30 months, whatever the employer's size and whether the patient still works. Medicare's booklet for kidney patients (November 2025) says the period starts in the first month of eligibility, usually the fourth month of dialysis, even if the patient has not enrolled. See our coordination of benefits guide.
Since January 1, 2026, the CMS-0057-F final rule has required Medicare Advantage, Medicaid and CHIP plans to decide expedited prior authorization requests within 72 hours and standard ones within seven calendar days, with a specific denial reason. In the AMA's 2025 survey of 1,000 physicians (released May 2026), physicians averaged 40 prior authorizations and about 13 staff and physician hours a week.
| Rule | Source | What the VMA checks |
|---|---|---|
| ESRD Medicare usually starts the third month after dialysis begins; sooner with self-dialysis training or a transplant | 42 CFR 406.13 | Dialysis start and Medicare effective dates on file |
| Group health plan pays first for up to 30 months, regardless of employer size or employment | CMS MSP Manual ch. 2, §20 | Employer coverage asked about at intake; coordination end month logged |
| ESRD-only Medicare ends after the 36th month following a transplant; a Part B benefit for immunosuppressive drugs only is available | 42 CFR 406.13 | Transplant date and coverage end date logged |
| Home dialysis telehealth needs in-person assessments monthly for 3 months, then every 3 consecutive months | Social Security Act §1881(b)(3)(B) | In-person dates booked before any telehealth month |
| Telehealth anywhere in the US through Dec 31, 2027; POS 10 at home, POS 02 elsewhere | CMS telehealth FAQ (Feb 2026) | Patient location and place of service recorded |
| Kidney disease education: stage IV CKD, a referral, up to 6 one-hour sessions | 42 CFR 410.48 | Stage in the note; referral on file; sessions counted |
| MA, Medicaid and CHIP plans decide in 72 hours (expedited) or 7 days (standard) | CMS-0057-F; from Jan 1, 2026 | Request and due dates logged; denial reason saved |
| No chronic care management in the same service period as 90951–90970 | CMS MLN909188 (2025) | MCP status checked before CCM enrollment |
Sources: eCFR 42 CFR 406.13, 410.48 and 410.78 (2026); Social Security Act §1881; CMS Medicare Secondary Payer Manual ch. 2 (2022); Medicare booklet 10128 (2025); CMS telehealth FAQ (2026); CMS-0057-F fact sheet (2024); CMS MLN909188 (2025). Always check the member's current plan.
Medicare's telehealth flexibilities run through December 31, 2027, according to CMS's telehealth FAQ updated February 26, 2026. Until then, patients can receive telehealth anywhere in the United States, including at home. From January 1, 2028, most non-behavioral telehealth again requires a medical facility in a rural area.
Home dialysis is the lasting exception. Since 2019, 42 CFR 410.78 has counted the home and renal dialysis facilities as originating sites for the monthly home dialysis ESRD clinical assessment, with no geographic limit, as CMS's telehealth booklet (December 2025) confirms. Section 1881(b)(3)(B) of the Social Security Act requires in-person assessments monthly for the first 3 months of home dialysis, then at least once every 3 consecutive months. We plan the monthly access exam in person. See our telehealth billing guide and prior authorization guide.
See what slow or denied claims cost you
Enter your claim volume and denial rate to estimate what your nephrology practice is losing each month.
Nephrology marketing has two audiences: referring clinicians and patients looking for kidney care nearby. Both need clear pages, and tracking must respect HIPAA.
We build location pages, plain-language pages on CKD stages and treatment options, and a simple referral path that lists the records you want, such as recent labs. Earlier referrals matter: Medicare's education benefit starts at stage IV. Our cardiology billing page covers one common referral source.
HHS guidance on online tracking says tracking tools on login, appointment or symptom pages can collect protected health information, and a cookie banner is not a HIPAA authorization. A June 2024 court order vacated part of that guidance. We still keep tracking off referral and appointment forms unless the vendor signs a BAA.
Stay in-house if your staff track visits and payer order well. Use a billing-only vendor if claims are your only gap. Choose a combined partner when problems start at the front desk.
| Job | In-house team | Billing-only vendor | Four-pillar partner (RCM Finder) |
|---|---|---|---|
| Counting MCP visits and access exams | Rounding notes, if someone tallies them | Billed from what the practice sends | VMA logs visits; claim held to month end |
| Payer order for dialysis patients | Front desk, if trained | Fixed after a denial | Coordination and transplant dates logged first |
| Home dialysis telehealth schedule | Provider calendars | Not in scope | In-person dates booked on the required cadence |
| Kidney education and care management | Case by case | Billed if the practice tracks it | Stage, referral, sessions and MCP conflicts checked |
| Referral growth | A separate agency, or nobody | Not included | Marketing tied to referrals and first visits |
| Reporting | EHR reports | Claim reports only | Portal dashboards, referral to paid claim |
| Cost structure | Salaries, benefits, turnover | Varies; ask how fees are set | Quoted after a free practice audit |
We will tell you in the audit if you need only one pillar.
We start with a free audit and change nothing until you see the findings. We build our billing pipeline around how claims actually move through a practice: registration, charge entry, submission, payment and follow-up. For nephrology, we add the checks on this page.
We review recent MCP, procedure and education claims, denials, and how visits and payer order are recorded.
We put a Business Associate Agreement in place before accessing patient data. Then we work inside your existing EHR (for example PrognoCIS, eClinicalWorks or athenahealth).
Your Medicare contractor's ESRD guidance and your plans' authorization lists become a monthly checklist and portal workflow rules.
VMAs log visits and confirm coverage. Claims go out after month end and are worked through denials and A/R.
Each week we review denials by reason, A/R days, MCP claims by visit tier and new referrals.
Talk to us about your nephrology practice
Tell us how many dialysis units you round at and your hardest payer. We will tell you honestly whether we fit.
Any billing vendor handling your patients' data is a HIPAA business associate. Get a Business Associate Agreement before any access, and check how access is limited and logged.
HHS guidance names billing and claims processing as business associate work; subcontractors need their own agreement. The minimum necessary standard limits use to what each task needs. The Security Rule's technical safeguards require access control, audit controls, integrity controls, person or entity authentication and transmission security.
We use role-based access, audit logging and encrypted (HTTPS) connections, and we put a Business Associate Agreement in place before accessing patient data. For your own side, use our HIPAA compliance checklist for medical practices.
We would rather tell you now than after you sign. Here is where we fit and where we do not.
A good fit if you are
Probably not a fit if you are
What we would do first if we were running your practice's revenue cycle tomorrow.
We record each MCP visit, who furnished it and whether it included the access exam on the day it happens. Month-end reconstruction is where tiers get lost.
Claims dated before month end cannot be paid, so we hold them and bill the full date span.
The 30-month coordination period starts whether or not the patient enrolls. We log its end month so Medicare becomes primary on time.
Before any telehealth month, we calendar the required in-person assessments: monthly for three months, then at least every three months.
We check that the CKD stage in the note matches the code and that linked diabetes or hypertension is coded in the order the tabular instructs.
With a referral, Medicare covers up to six one-hour sessions for stage IV patients. We count sessions so none is billed past the limit.
They cover coding support, claim scrubbing, submission, denial management and A/R follow-up for nephrology visits, ESRD monthly capitation claims, dialysis access procedures and kidney disease education. A good service also tracks visit counts, payer order for dialysis patients and transplant dates. We add front-desk assistants, referral marketing and a claims portal. Pricing depends on your patient mix and which pillars you need, so we quote it after a free practice audit.
Start with the setting. For a full month in a dialysis facility, codes 90951–90962 depend on the patient's age at the end of the month and the number of face-to-face visits: four or more, two or three, or one. Full home dialysis months use 90963–90966 by age. Partial months use per-day codes 90967–90970, with units for the dialysis days. In facility months, one visit must include a vascular access exam. Bill after the month ends. These rules follow Noridian and First Coast guidance; other contractors may differ.
Through December 31, 2027, Medicare telehealth is available anywhere in the US, including at home. After that, most non-behavioral telehealth again needs a medical facility in a rural area. Home dialysis is the lasting exception: the home and dialysis facilities are allowed sites for the monthly home dialysis assessment, with no geographic limit. The patient still needs in-person assessments monthly for the first three months, then at least once every three consecutive months.
During the 30-month coordination period, the employer or union group health plan pays first and Medicare pays second. That holds regardless of employer size or whether the patient still works. Medicare's booklet says the period starts in the first month the patient would be eligible because of kidney failure, usually the fourth month of dialysis, even if not enrolled. After the 30th month, Medicare becomes primary.
Yes, for patients with stage IV chronic kidney disease who are referred by the physician managing their kidney condition. Part B pays for up to six one-hour sessions, individual (G0420) or group (G0421, two to 20 people). Physicians, physician assistants, nurse practitioners and clinical nurse specialists can furnish them; renal dialysis facilities cannot. Content must cover managing other conditions, treatment options including transplant, and an outcomes assessment.
Not for the same service period as the ESRD monthly codes. CMS's chronic care management booklet (June 2025) says CCM cannot be billed during the same service period as CPT 90951–90970. For CKD patients who are not on dialysis, CCM can apply when they have two or more chronic conditions expected to last at least 12 months, with the patient's consent obtained before billing.
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Pricing is quoted after the audit, based on your volume and the services you choose. Prefer to talk? Call +1 (302) 556-2288.
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