Dialysis Services (In/Outpatient) Same Date as an Evaluation & Management Service


  • CPT codes 90935 and 90937 are used to report inpatient ESRD hemodialysis and outpatient hemodialysis performed on non-ESRD patients (e.g., patients in acute renal failure requiring a brief period of dialysis prior to recovery)
  • CPT codes 90945 and 90947 are used to report all non-hemodialysis procedures
  • All four of these codes include payment for any evaluation and management (E/M) services related to the patient's renal disease that are provided on the same date as the dialysis service
  • Therefore, payment for all E/M services is bundled into the payment for CPT codes 90935, 90937, 90945 and 90947, except for the following E/M services which may be reported on the same date as a dialysis service if they are "significant and separately identifiable" and meet any medical necessity requirements:

CPT CodesDescription
99201–99205 Office or Other Outpatient Visit for a New Patient
99211–99215 Office or Other Outpatient Visit for an Established Patient
99221–99223 Initial Hospital Care for a New or Established Patient
99238–99239 Hospital Discharge Day Management Services
99251–99255 Initial Inpatient Consultations, New or Established Patient
99291–99292 Critical Care Services

In the absence of one of these codes being reported with CPT modifier 25 and meeting the medical necessity requirements, only the dialysis service will be considered for coverage. Furthermore, payment is not allowed for more than one dialysis service per day.

References

  • Pub. 100-02 (PDF, 468 KB), Chapter 11: End Stage Renal Disease
  • Pub. 100-04 (PDF, 1.86 MB), Chapter 8: Outpatient ESRD Hospital, Independent Facility, and Physician/ Supplier Claims
  • Pub. 100-04 (PDF, 569 KB), Chapter 16: Laboratory Services
  • MLN Matters article MM7520 (PDF, 94 KB): Clarification of Payment for ESRD-Related Services Under the Monthly Capitation Payment




Last Updated: 05/29/2020