The Ultimate Guide to Nephrology Coding and Billing
Proper billing and coding are crucial aspects of running a successful nephrology practice. Accurate coding ensures that healthcare providers are appropriately reimbursed for their services, while proper billing practices help maintain financial stability and compliance with regulations. In the complex field of nephrology, where services range from dialysis to kidney transplants, understanding billing and coding guidelines is essential for maximizing revenue and minimizing compliance risks.
In this comprehensive guide to nephrology billing and coding, we will delve into the intricacies of coding for nephrology services, including common CPT codes, modifiers, and diagnosis codes specific to kidney diseases. We will also explore evaluation and management coding, dialysis services, kidney transplant procedures, kidney biopsy coding, nephrology procedures, documentation best practices, compliance, and auditing. By the end of this guide, nephrology healthcare providers will have a solid foundation in billing and coding practices tailored to their specialty.
Understanding Nephrology Codes
Common CPT codes used in nephrology
Nephrology practices utilize a wide range of CPT (Current Procedural Terminology) codes to represent their services accurately. Some of the most commonly used CPT codes in nephrology include:
- 90935: Hemodialysis procedure with single physician evaluation
- 90937: Hemodialysis procedure requiring repeated physician evaluations
- 90945: Dialysis procedure other than hemodialysis (e.g., peritoneal dialysis, hemofiltration, or other dialysis procedures requiring physician supervision)
- 50370: Removal of kidney transplant
- 50380: Reimplantation of kidney transplant
- 50200: Percutaneous needle biopsy of kidney
Nephrology practices must stay updated on the latest CPT code changes and use the appropriate codes for the services rendered.
Modifiers and how to use them correctly
Modifiers are two-digit codes that provide additional information about a procedure or service. Proper use of modifiers is essential for accurate reimbursement and compliance. Some commonly used modifiers in nephrology include:
- 25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service
- 59: Distinct procedural service
- 76: Repeat procedure or service by the same physician
- 77: Repeat procedure by another physician
Nephrology practices should clearly understand modifier usage and apply them correctly to avoid claim denials or audits.
Diagnosis codes (ICD-10) for kidney diseases
Accurate diagnosis coding is crucial for supporting medical necessity and ensuring appropriate reimbursement. Nephrology practices should be familiar with the most common ICD-10 diagnosis codes related to kidney diseases, such as:
- N18.1: Chronic kidney disease, stage 1
- N18.2: Chronic kidney disease, stage 2 (mild)
- N18.3: Chronic kidney disease, stage 3 (moderate)
- N18.4: Chronic kidney disease, stage 4 (severe)
- N18.5: Chronic kidney disease, stage 5
- N18.6: End-stage renal disease
- N01.9: Rapidly progressive glomerulonephritis, unspecified
Proper documentation and use of ICD-10 codes are essential for supporting medical necessity and avoiding claim denials.
Evaluation and Management (E/M) Coding
New patient vs. established patient visits
Distinguishing between new and established patient visits is crucial in E/M coding for nephrology practices. New patient visits involve patients who have not received any professional services from the physician or another physician of the same specialty within the past three years.
Established patient visits, on the other hand, are for patients who have received professional services from the physician or another physician of the same specialty within the past three years. Identifying and coding new versus established patient visits ensures accurate reimbursement and compliance with coding guidelines.
Selecting the appropriate E/M code level
Selecting the correct E/M code level is essential for accurately reflecting the complexity of the patient encounter and ensuring proper reimbursement. Nephrology providers should consider factors such as history, examination, and medical decision-making when determining the appropriate E/M code level. The levels of E/M coding range from straightforward to highly complex, and selecting the most accurate code based on the documentation provided is crucial for compliance and optimal reimbursement.
Time-based coding vs. medical decision making
In nephrology practices, providers often face the choice between time-based coding and medical decision-making when determining the E/M code level. Time-based coding allows providers to select an E/M code based on the total time spent on the patient encounter, including face-to-face and non-face-to-face time spent on the patient’s care.
On the other hand, medical decision-making involves assessing the complexity of the patient’s condition, the risk of complications or morbidity, and the management options considered. Providers should carefully document time spent and medical decision-making processes to support their E/M code selection accurately.
Dialysis Services
Inpatient and outpatient dialysis codes
Nephrology practices must be well-versed in the appropriate CPT codes for inpatient and outpatient dialysis services. For inpatient dialysis, common codes include:
- 90935: Hemodialysis procedure with single physician evaluation
- 90937: Hemodialysis procedure requiring repeated physician evaluations
- 90945: Dialysis procedure other than hemodialysis (e.g., peritoneal dialysis, hemofiltration, or other dialysis procedures requiring physician supervision)
For outpatient dialysis, the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) utilizes a bundled payment approach, which includes codes for:
- Hemodialysis treatments (CPT codes 90951-90970)
- Peritoneal dialysis treatments (CPT codes 90991-90993)
Coding for hemodialysis, peritoneal dialysis, and continuous renal replacement therapy (CRRT)
Nephrology practices should be familiar with the specific CPT codes for various dialysis modalities:
- Hemodialysis: 90935, 90937
- Peritoneal dialysis: 90945, 90993
- Continuous renal replacement therapy (CRRT): 90945
Selecting the appropriate code based on the specific dialysis modality performed and the number of physician evaluations required is crucial. Accurate coding ensures proper reimbursement and reflects the complexity of the patient’s condition and the services provided.
Coding for dialysis access procedures
Nephrology practices should also be knowledgeable about the CPT codes for dialysis access procedures, such as:
- 36147: Introduction of needle or intracatheter, arteriovenous shunt created for dialysis (graft or fistula)
- 36148: Introduction of needle or intracatheter for dialysis, arteriovenous shunt created for dialysis (graft or fistula)
- 36800: Insertion of cannula for hemodialysis, other purpose (separate procedure)
- 36810: Insertion of temporary internal jugular vein cannula for dialysis (separate procedure)
- 36815: Insertion of a permanent tunneled dialysis catheter without imaging guidance
Kidney Transplant Procedures
Pre-transplant evaluation and donor nephrectomy codes
Nephrology practices involved in kidney transplantation should be familiar with the CPT codes for pre-transplant evaluation and donor nephrectomy procedures:
Pre-transplant evaluation:
- 50547: Laparoscopy, surgical; donor nephrectomy (including distal ureterectomy and ureteral reimplantation, when performed)
- 50548: Laparoscopy, surgical; donor nephrectomy, open, with manual assistance
Donor nephrectomy:
- 50320: Donor nephrectomy, including preparation and maintenance of allograft; open (separate procedure)
- 50325: Backbench standard preparation of cadaver donor renal allograft before transplantation, including dissection and removal of perinephric fat, diaphysis of the ureter and renal artery(s), as necessary
Kidney transplant surgery codes
Nephrology practices should be familiar with the CPT codes for kidney transplant surgery:
- 50340: Removal of the donor’s kidney, without manipulation, open
- 50360: Renal allotransplantation, implantation of graft; without recipient nephrectomy
- 50365: Renal allotransplantation, implantation of graft with recipient nephrectomy
- 50370: Removal of transplanted renal allograft
Post-transplant care and immunosuppressive therapy
Nephrology practices should also be knowledgeable about the CPT codes for post-transplant care and immunosuppressive therapy:
Post-transplant care:
- 99231-99233: Subsequent hospital care
- 99238-99239: Hospital discharge day management
Immunosuppressive therapy:
- J7500: Azathioprine, oral, 50 mg
- J7501: Azathioprine, parenteral, 100 mg
- J7502: Cyclosporine, oral, 100 mg
- J7507: Tacrolimus, extended-release, oral, 0.1 mg
Kidney Biopsy Coding
Percutaneous kidney biopsy codes
Nephrology practices should be familiar with the CPT codes for percutaneous kidney biopsies:
- 50200: Percutaneous needle biopsy of kidney
- 50205: Percutaneous renal biopsy by trocar or needle
- 50390: Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous
These codes should be selected based on the specific technique used for the kidney biopsy procedure.
Coding for image guidance and anesthesia
Nephrology practices should also be knowledgeable about the CPT codes for image guidance and anesthesia used during kidney biopsy procedures:
Image guidance:
- 76942: Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation
- 77012: Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation
Anesthesia:
- 00740: Anesthesia for procedures on the upper abdominal wall and viscera; not otherwise specified
- 00670: Anesthesia for procedures on the adrenal gland; total adrenalectomy
Proper image guidance and anesthesia coding ensure accurate reimbursement and reflect the additional resources and expertise required for safe and effective kidney biopsy procedures.
Nephrology Procedures
Renal angiography and angioplasty codes
Nephrology practices should be familiar with the CPT codes for renal angiography and angioplasty procedures:
Renal angiography:
- 75625: Aortography, abdominal, by serialography, radiological supervision and interpretation
- 75630: Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation
Renal angioplasty:
- 35471: Transluminal balloon angioplasty, percutaneous; renal or other visceral artery
- 35472: Transluminal balloon angioplasty, percutaneous; renal or other visceral artery, each additional vessel (List separately in addition to code for primary procedure)
Coding for renal stent placement
Nephrology practices should also be knowledgeable about the CPT codes for renal stent placement:
- 37236: Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery
- 37237: Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code for primary procedure)
Coding for renal denervation procedures
Nephrology practices should also be familiar with the CPT codes for renal denervation procedures:
- 0338T: Transcatheter renal denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural road mapping and radiological supervision and interpretation, when performed; unilateral
- 0339T: Transcatheter renal denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural road mapping and radiological supervision and interpretation, when performed; bilateral
Conclusion
As a nephrology practice, it is crucial to prioritize accurate billing and coding to ensure optimal reimbursement, compliance, and financial health. By implementing the best practices outlined in this guide and utilizing the available resources, you can improve your billing and coding processes, reduce the risk of errors and denials, and focus on providing high-quality care to your patients.
Remember, investing time and resources into improving your billing and coding practices is an investment in the long-term success and sustainability of your nephrology practice.
Resources for further learning
For nephrology practices looking to expand their knowledge and stay up-to-date with the latest billing and coding guidelines, we recommend the following resources:
- American Society of Nephrology (ASN) Coding and Reimbursement resources: https://www.asn-online.org/education/nephsap/
- Centers for Medicare & Medicaid Services (CMS) nephrology-specific billing and coding guidelines: https://www.cms.gov/medicare-coverage-database/view/article.aspx
- American Medical Association (AMA) CPT coding resources: https://www.ama-assn.org/practice-management/cpt
