2025 CPT code 90966
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Medicine Services and Procedures - Dialysis Services and Procedures Medicine Feed
Medical management of home dialysis for ESRD patients (age 20+) for a full month.
Modifiers may be applicable depending on circumstances (e.g., 52 for reduced services, 76/77 for repeat services, etc.). Consult the CPT manual and payer guidelines.
Medical necessity is established by the patient's diagnosis of ESRD and their requirement for home dialysis. Documentation should support the medical complexity and the need for the physician's ongoing management.
The physician or qualified healthcare professional is responsible for comprehensive medical management of the patient's ESRD, including all aspects of their home dialysis treatment.
In simple words: This code covers a doctor's care for one full month for a person over 20 with kidney failure who does home dialysis. The doctor manages their care, including checkups, creating a dialysis plan, phone calls, and support for the patient and their family.
CPT code 90966 represents the comprehensive medical management of end-stage renal disease (ESRD) for home dialysis patients aged 20 years or older during a complete calendar month.This includes evaluation and management of ESRD care, establishment and revision of dialysis schedules and prescriptions, development and modification of short- and long-term care plans, telephone and electronic communication with the patient, care coordination, and regular counseling and support for the patient and/or caregivers.The service requires at least one face-to-face visit per month.
Example 1: A 65-year-old male with ESRD on home hemodialysis requires monthly management. The physician reviews labs, adjusts medications, and addresses concerns via phone and in-person visit., A 22-year-old female patient starts home peritoneal dialysis.The physician provides initial training, establishes a care plan, and provides monthly monitoring and adjustments., A 70-year-old patient experiences complications with their home dialysis catheter. The physician performs an in-person visit, orders tests, and adjusts the treatment plan to address the issue.
* Comprehensive medical history and physical examination (at least annually)* Lab results (including complete blood counts, electrolytes, and BUN/creatinine levels)* Dialysis records (frequency, duration, access type)* Medication reconciliation and review.* Documentation of any patient or caregiver education provided.* Records of all telephone and electronic communications.* Documentation of at least one face-to-face visit per month.
** The monthly capitation payment for home dialysis under Medicare requires at least one face-to-face visit per month.The assessment and ongoing management must be provided by the billing physician or another Medicare-certified practitioner within the same group.
- Revenue Code: P9A (Dialysis Services)
- RVU: Refer to the CMS Physician Fee Schedule for current RVU values.
- Global Days: This code covers a full calendar month of services.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Fee Schedule: Refer to the CMS Physician Fee Schedule for historical fee data.
- Specialties:Nephrology
- Place of Service:Home