ESRD Monthly Capitation Payment (MCP) Coding and Frequency Limitations


The following CPT codes represent monthly End Stage Renal Disease (ESRD)-related services, also known as dialysis management services and monthly capitation payment (MCP) services. Submit the appropriate code based on the number of direct patient care services furnished by a physician or qualified practitioner. Use the CPT code appropriate for the patient’s age and number of face-to-face visits. 

CPT Codes
Outpatient: 90951–90962
Home: 90963–90966

Date of Service
Submit the claim after the end of the month coding the date of service as follows.

  • For the first calendar month the patient begins dialysis treatments, submit a date of service span on one detail line consisting of the first date the dialysis treatments begin through the last date of the same calendar month. Days/Units should be submitted as "1."
  • For subsequent months when a full calendar month of care is provided, submit a date of service span on one detail line consisting of the first date of the calendar month and the last date of the same calendar month. Days/Units should be submitted as "1."

Frequency Limitation
Only one MCP service in CPT range 90951–90966 is permitted per calendar month, even if multiple physicians are involved in the patient’s care.

Documentation

  • The medical record must contain a record of the complete assessment and be available upon request
  • The plan of care must be established (for new patients) or updated as needed (for established patients)
  • NPPs are permitted to perform these services based on their scope of practice, as defined by state law

Related Services
I
f a physician other than the MCP physician provides medically necessary services (e.g., test interpretations) that would normally be included or bundled into the MCP, Medicare can make separate payment for the related services. However, Medicare considers these circumstances to be rare.

ESRD-related Services for Less Than a Month
To submit for less than a month of ESRD/dialysis management care, use CPT code 90967–90970, based on the patient’s age and utilize the From/To Date of Service and Days/Units fields to reflect the number of visits.

Reference
CMS IOM Pub. 100-4, Claim Processing Manual, Chapter 8, Section 140 (PDF, 981 KB).





Last Updated: 05/29/2020