2025 CPT code 90967
(Active) Effective Date: N/A Revision Date: N/A Medicine - End-Stage Renal Disease (ESRD) Services Medicine Services and Procedures > Dialysis Services and Procedures Feed
End-stage renal disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age.
Modifiers may apply depending on the circumstances of service.Consult the CPT manual and payer guidelines for appropriate modifier use.
Medical necessity is established by documenting the patient's ESRD diagnosis, the need for dialysis, and the reason for less-than-a-full-month service.Documentation should justify the daily services provided and support the medical necessity of the treatment.
The physician or other qualified healthcare professional manages all daily outpatient ESRD-related services for the patient for less than a full month.
In simple words: This code covers daily medical care for a child under 2 years old with kidney failure who needs dialysis but only receives it for part of a month.This might be due to a short stay, travel, hospitalization, or a transplant. The doctor bills for each day of care provided.
This CPT code reports end-stage renal disease (ESRD)-related services for dialysis patients under 2 years old who receive dialysis for less than a full month.It's billed per day and applies to various situations, including partial-month home dialysis, services for transient patients, cases with face-to-face visits but lacking a complete assessment (possibly due to hospitalization, death, or transplant), or when a patient changes providers mid-month.The code encompasses daily management of outpatient ESRD services.
Example 1: A 1-year-old patient with ESRD receives home dialysis for 15 days in July due to a planned family vacation. Code 90967 is billed for each of the 15 days of service., A 6-month-old with ESRD is hospitalized for 10 days in August, receiving dialysis during this time. After discharge, they receive 10 days of outpatient dialysis services before receiving a kidney transplant. Code 90967 would be used for the 10 outpatient days, along with appropriate inpatient codes for the hospitalization period., An 18-month-old patient with ESRD starts dialysis on October 15th and receives services until they are transferred to another facility on October 28th. Code 90967 would be billed for each day of service from October 15th to October 28th.
Detailed daily records of ESRD-related services, including dates of service, types of services provided (e.g., assessment, medication management, etc.), and any complications encountered.Records should reflect the reason for less than a full month of service (e.g., hospitalization, transplant, etc.).
** Medicare considers a month as a calendar month for ESRD-related service payments.The first month of dialysis is from the start date to the end of that calendar month.
- Revenue Code: P9A (Dialysis Services)
- RVU: Data not available.Consult the CMS fee schedule for current RVU values and reimbursement rates.
- Global Days: This code is billed per day, not within a global period.
- Payment Status: Active
- Modifier TC rule: Not applicable.This is a comprehensive service code.
- Fee Schedule: Data not available. Consult historical CMS fee schedules for prior reimbursement rates.
- Specialties:Nephrology, Pediatric Nephrology
- Place of Service:Office, Home, Hospital (Inpatient and Outpatient), Dialysis Center