According to reports from the Centers for Disease Control and Prevention (CDC), about 37 million US adults (2019 statistics) – that is, 1 out of every 7 or 15 percent of the adult population suffer from chronic kidney disease (CKD). In fact, as many as 9 in 10 adults with CKD do not know they have CKD. The increasing prevalence of chronic kidney disease in the number of Americans is due to several chronic conditions such as diabetes, hypertension and heart disease. The demand for kidney dialysis is expected to increase with the growth in the elderly population in the US. However, with the increasing body of regulations, reporting nephrology diagnoses and treatment has become challenging. Medical coding outsourcing helps healthcare providers ensure accurate reporting of services rendered for appropriate reimbursement.
Dialysis is needed to clean the blood when the kidneys stop functioning properly. There are two main types of dialysis – hemodialysis and peritoneal dialysis. Hemodialysis is a unique method to treat advanced kidney failure and help people carry on an active lifestyle despite failing kidneys. The procedure involves pumping the patient’s blood through a machine for filtration and passing it back into the body. It helps control blood pressure and balance important minerals, such as potassium, sodium, and calcium, in the blood. The procedure is generally carried out at a medical facility 3 days a week, with a session lasting between 3-5 hours. The time needed for a dialysis depends on several factors like – how well the kidneys are functioning, how much waste and fluid builds up inside the body (between the treatments), and the height and weight of the patient.
What Happens During Hemodialysis?
During the hemodialysis procedure, the blood travels from the body into a dialysis machine wherein it goes through a filter called a dialyzer. The dialyzer filter cleans the blood by removing some of the waste and extra fluid. The cleaned blood then travels through tubes from the dialysis machine back into the body. The final results of the dialysis procedure depend on the extent of the kidney injury – whether it is acute or severe.
Medicare Coverage for Dialysis
Medicare covers dialysis and most treatments that involve end stage renal disease (ESRD) or kidney failure. It covers many of the supplies and services needed for dialysis, including –
- Hospital inpatient dialysis treatments
- Outpatient dialysis – from a Medicare-certified hospital or free-standing dialysis facility
- Home dialysis training (also called self-dialysis) from a dialysis facility. If a Medicare patient needs dialysis, a clinic that is certified to provide home training and support can bill Medicare for a certain number of training sessions, depending on the modality. CMS pays up to 15 training sessions for peritoneal dialysis and 25 sessions for hemodialysis. This includes –
- Training for the patient and caregivers who will provide home dialysis
- Home dialysis equipment and supplies
- Medications related to treatment (medication is only covered when overseen by a doctor)
- Other services and supplies, such as laboratory tests
Medicare may cover ambulance services to and from the home to the closest dialysis facility if the physician provides written orders certifying that it’s a medical necessity. Services and supplies not covered by Medicare include –
- Payment for aides to help with home dialysis
- Lost pay during home dialysis training
- Lodging during treatment
- Blood or packed red blood cells for home dialysis (unless included with a doctor’s service)
CPT Codes to Report Hemodialysis Procedure
- 90935 – Hemodialysis procedure with single evaluation by a physician or other qualified healthcare professional
- 90937 – Hemodialysis procedure requiring repeated evaluations, with or without substantial revision of dialysis prescription – This code is used to report services provided by the physician during the patient’s hemodialysis treatment.
- 90940 – Hemodialysis access flow study to determine blood flow in grafts and arteriovenous fistulae by an indicator method
CPT Codes for Miscellaneous Dialysis Services and Other Dialysis Procedures (90945-90947)
This code range covers services not found in other code ranges for dialysis procedures such as peritoneal dialysis, hemofiltration, and other continuous renal replacement therapies.
- 90945 Dialysis procedure other than hemodialysis (e.g. peritoneal, hemofiltration) with single evaluation by a physician or other qualified healthcare professional
- 90947 Dialysis procedure other than hemodialysis (e. g. peritoneal, hemofiltration) requiring repeated evaluations, by a physician or other qualified healthcare professional, with or without substantial revision of dialysis prescription
Hemodialysis Access Maintenance Codes
- 36901 AV shuntogram
- 36902 AV shuntogram and angioplasty of peripheral dialysis segment
- 36903 AV shuntogram, stent placement, and angioplasty of peripheral dialysis segment
- 36904 AV shuntogram and percutaneous mechanical thrombectomy
- 36905 AV shuntogram, angioplasty, and percutaneous mechanical thrombectomy
- 36906 AV shuntogram, stent placement, angioplasty, and percutaneous mechanical
- +36907 Angioplasty of central dialysis segment (add-on)
- +36908 Stent placement and angioplasty of central dialysis segment (add-on)
- +36909 Embolization, main circuit or accessory veins
Medical billing and coding for nephrology conditions can be complex. Partnering with an experienced nephrology medical billing company could help providers ensure accurate reporting of hemodialysis and other procedures, and ensure accurate claim submissions.