What makes nephrology billing services different
Nephrology billing services center on dialysis: the procedure codes for each treatment, the monthly capitation payment for physician oversight and the bundled payment system that covers the dialysis facility's services. A nephrology practice bills the physician side — the dialysis procedures, the monthly management and the hospital visits — while the facility bills the ESRD prospective payment bundle. Keeping those two sides consistent, month after month, is the core of the work. Fastora's certified billing and coding professionals handle these claims for nephrology practices as part of our wider medical billing services.
Nephrology patients are among the most consistently insured — most dialysis patients qualify for Medicare regardless of age — but the billing rules are among the most specific in medicine. Monthly capitation codes change with patient age and visit count, inpatient dialysis follows different rules from outpatient, and acute kidney injury is billed differently from end-stage renal disease.
Dialysis billing: ESRD procedures and the facility bundle
Outpatient dialysis procedures are reported per treatment: 90935 for a single hemodialysis evaluation with one physician assessment, 90937 when repeated evaluations are required, and 90945 through 90947 for peritoneal dialysis by day. The code must match what actually happened at the treatment — including who performed the assessment.
The dialysis facility's services — the treatment itself, labs, drugs and supplies — are paid under the ESRD prospective payment system as a bundle, not fee-for-service. The physician claim and the facility claim describe the same month of care from different sides, so diagnosis coding and treatment dates have to agree or both sides draw scrutiny.
Monthly capitation and visit tracking
Physician management of outpatient dialysis is paid monthly through the monthly capitation payment codes, 90951 through 90962, which vary by patient age and by how many face-to-face visits the physician provided that month. Four or more visits, two to three visits and one visit each map to different codes.
Visit counts have to be tracked per patient per month — a month with three documented visits bills differently from a month with four. Hospital visits during the month, home dialysis oversight and partial months when dialysis starts or the patient is hospitalized all change the coding, so the month is reconstructed from the visit record before the claim is built.
Eligibility, coordination of benefits and authorization
We run eligibility and benefits checks for new dialysis patients, confirming Medicare entitlement, the coordination-of-benefits period when employer coverage is primary, and secondary coverage. Transplant workups, vascular access procedures and immunosuppressive drugs often need prior authorization from commercial and Medicare Advantage plans.
The thirty-month coordination period for ESRD Medicare is a frequent source of mis-billed claims: during that window the employer plan pays first, and claims sent to Medicare as primary will deny. We verify the coordination period at intake and recheck it on schedule.
Nephrology coding: key codes and inpatient rules
| Code | Descriptor (summary) | Billing note |
|---|---|---|
| 90935 | Hemodialysis procedure with single evaluation | One physician assessment at the treatment |
| 90937 | Hemodialysis procedure requiring repeated evaluations | Multiple assessments documented |
| 90945 | Dialysis other than hemodialysis, single evaluation | Peritoneal dialysis, per day |
| 90947 | Dialysis other than hemodialysis, repeated evaluations | Peritoneal dialysis, per day |
| 90951-90954 | ESRD monthly capitation, adult, by visit count | Visits tracked per patient per month |
| 90999 | Unlisted dialysis procedure | Used when no specific code describes the service |
Inpatient dialysis is billed per day with the inpatient dialysis codes rather than the monthly capitation, and the transition between inpatient and outpatient status mid-month has to be split correctly. Acute kidney injury dialysis follows the inpatient rules even in some outpatient settings, depending on the payer. Our medical coding team reviews dialysis claims against the treatment and visit records before submission.
Common nephrology billing denials and how we prevent them
| Denial | Typical cause | Prevention step |
|---|---|---|
| Capitation code mismatch | Visit count for the month does not support the code billed | Visits reconstructed per patient per month before billing |
| Coordination-of-benefits denial | Claim sent to Medicare during the employer-primary period | Coordination period verified at intake and rechecked |
| Inpatient/outpatient split error | Dialysis days misallocated across settings | Treatment dates split by setting before coding |
| Duplicate dialysis billing | Physician and facility claims overlapping | Physician-side services separated from the facility bundle |
| Access procedure bundled | Vascular access work billed without distinct support | Access procedures coded to the operative note |
Every claim passes our Advanced Pre-Submission Claim Review before submission. Denials that still occur are worked by our denial management team, which corrects and resubmits or appeals with the record, and open balances are followed up by payer and age.
Credentialing for nephrologists
Nephrologists enroll with Medicare and commercial plans as physicians, and new physicians need to be linked to the group before dialysis and capitation claims pay in network. Physicians who round at multiple dialysis facilities need each location tied to their enrollment.
Our credentialing and enrollment service tracks each file through a nine-stage process, from document collection and NPI and CAQH setup to payer applications, follow-ups and final approval.
How Fastora supports nephrology billing
Fastora works inside your existing EHR/PM system under the user access you grant, with no software to install and no hidden setup fees. You get a dedicated account contact, transparent dashboards, monthly performance reporting and a monthly review call.
Fees are quoted after a free assessment. To see how your current claims hold up, start with a free billing assessment.
Nephrology and ESRD billing
Nephrology medical billing centers on dialysis: the monthly capitated payment for ESRD patients, the G-codes that report the dialysis-related services, and the vascular access procedures that keep treatment going. ESRD billing carries its own eligibility rules through Medicare — the coordination period with employer plans, the transition to Medicare primary — and the monthly capitation only pays in full when the visit count and documentation support it. We track the ESRD timeline per patient alongside the standard cycle of eligibility, claims, denials, and follow-up. Related: free medical billing audit, medical billing services, pricing.