Nephrology Medical Billing Services
ESRD PPS Compliance · Dialysis Billing · Medicare Capitation · Denial Management · CROWNWeb Reporting
Serving Florida nephrology practices and dialysis centers — based in St. Petersburg, FL
Why Nephrology Billing Requires a Specialist
Nephrology is one of the most Medicare-intensive specialties in medicine. More than 80% of a typical practice's revenue flows through Medicare or Medicare Advantage—and all ESRD patients qualify for Medicare regardless of age under 42 U.S.C. §426A. A single compliance error can affect the majority of your claims simultaneously.
The core complexity is the ESRD Prospective Payment System (PPS)—a bundled payment model (42 CFR 413.170–413.235) that folds 150+ dialysis-related items into one composite rate per treatment. Items in the bundle include:
- Saline, heparin, catheters, and all dialysis supplies
- Routine dialysis labs (BUN, creatinine, CBC, phosphorus, PTH)
- Epoetin alfa (J0885) and other erythropoiesis-stimulating agents
- IV iron, vascular access management, and patient education
Billing any of these separately for an ESRD patient triggers automatic denial. Practices that bill EPO separately for 200 ESRD patients can forfeit $160,000+ annually—and create False Claims Act exposure.
A second critical distinction: AKI (acute kidney injury) patients are billed fee-for-service under the same CPT codes as ESRD patients, but PPS bundling rules do not apply. EMR systems that default all dialysis patients to ESRD status cause revenue loss on AKI fee-for-service claims and compliance risk on ESRD claims.
Medsure RCS provides dedicated nephrology medical billing services staffed by Certified Professional Coders (CPC) with nephrology specialty certification from the AAPC. Our billing workflows are built around ESRD PPS, ESRD MCP coding, CROWNWeb reporting, and the ESRD Quality Incentive Program—not generic medical billing procedures adapted for nephrology.
The ESRD/AKI distinction at charge entry is the most consequential billing decision in nephrology — and the one most EMR systems get wrong by default.Medsure RCS Nephrology Billing Practice Note — 42 CFR 413 Compliance
Nephrology Billing Services We Provide
Our nephrology revenue cycle management covers every phase of the billing workflow, from charge capture and ESRD status validation through final payment posting and denial resolution.
Dialysis Billing — Hemodialysis and Peritoneal Dialysis
We code and submit all dialysis modalities: in-center hemodialysis (CPT 90935–90940), peritoneal dialysis (CPT 90945–90947), and home hemodialysis. Every claim includes an ESRD/AKI status validation step to prevent PPS bundling errors and ensure AKI patients are billed fee-for-service. See our complete dialysis billing services reference for full CPT code breakdowns and documentation requirements.
ESRD Monthly Capitation Payment (MCP) Billing
Nephrologist MCP codes (90951–90970) vary by patient age, monthly visit frequency, and dialysis modality. Selecting the wrong frequency code forfeits capitation revenue for the entire month. We review visit documentation monthly for every ESRD patient to ensure accurate MCP code selection. Our ESRD monthly capitation billing workflow targets 99%+ capitation collection.
Kidney Transplant Billing
Transplant billing involves a 90-day global period and UNOS-certified center documentation requirements. We handle CPT 50300–50380 for donor and recipient procedures, post-transplant high-complexity follow-up (99215), and immunosuppressant monitoring. Read our kidney transplant billing guide for the full coding reference.
Nephrology Denial Management
ESRD bundling errors, missing CMS Form 2728, and EPO dosing denials require specialty-specific resolution strategies—not generic appeal templates. Our nephrology denial management team resolves the top-five nephrology denial patterns with a structured root-cause analysis workflow. First-pass claim acceptance rate: 96%+.
Prior Authorization Services
Medicare requires no prior auth for standard dialysis under ESRD PPS, but commercial payers require authorization for home dialysis initiation, ESA therapy (J0885/J0886), and IV iron (J1756/J1439). Florida Medicaid requires prior auth for transplant evaluation and ESA. Our nephrology prior authorization team manages 48-hour ESA turnarounds and 72-hour home dialysis initiation authorizations.
ESRD QIP Compliance Monitoring
The ESRD Quality Incentive Program can reduce all Medicare ESRD payments by up to 2% for non-compliant facilities. We monitor Kt/V adequacy documentation (target ≥1.2), CROWNWeb submission timelines, catheter minimization tracking, and NHSN infection reporting. See our nephrology billing compliance guide for the full regulatory framework.
Chronic Kidney Disease (CKD) Billing
CKD stages 1–5 require ICD-10 stage documentation (N18.1–N18.5) at every encounter for accurate risk-adjustment coding (HCC). We capture CCM billing (CPT 99490–99491), MNT codes, and CKD E&M at the appropriate complexity level. Our CKD billing guide covers staging codes, HCC capture, and CCM documentation requirements.
Accounts Receivable Management
ESRD capitation is paid monthly by Medicare on a predictable schedule—but AKI high-value claims, ESA J-codes ($800–$3,000 per injection), and kidney transplant global periods create significant AR complexity. We target Days in AR under 38 and a Net Collection Rate above 94% for Medicare-heavy nephrology practices. See nephrology accounts receivable management for benchmarks and workflow details.
ESRD Billing: The Bundled Payment Model Explained
Understanding the ESRD Prospective Payment System is the prerequisite for accurate nephrology billing. Our Medicare ESRD billing specialists apply these rules daily—here is the foundation every nephrology billing team needs to know.
What the ESRD PPS Composite Rate Includes
The 2026 ESRD PPS base composite rate is $261.41 per dialysis treatment for most facilities (subject to wage index, low-volume, and other adjustments). This single rate is intended to cover all of the following:
- All dialysis supplies: saline, heparin, catheters, dialysate, needles, tubing
- Routine dialysis labs: BUN, creatinine, CBC, phosphorus, albumin, PTH, ferritin
- Erythropoiesis-stimulating agents: epoetin alfa (J0885), epoetin beta/Mircera (J0886)
- IV iron supplementation: ferumoxytol (J1439), iron sucrose (J1756)
- Vascular access management: maintenance, monitoring, and cannulation
- Social services, dietary counseling, patient education
- Home dialysis training (when facility-provided)
- Water treatment and dialysate preparation costs (facility)
- Most dialysis-related medications and biologics on the bundled drug list
Billing Alert: Any item on the bundled list billed as a separate claim for an ESRD patient will be automatically denied under consolidated billing rules. A practice billing EPO separately for 200 ESRD patients at an average of $800 per injection can forfeit $160,000+ annually—and create a False Claims Act exposure if the pattern is systematic.
What Is NOT Bundled and Can Be Billed Separately
These services can be billed separately even for confirmed ESRD patients:
- Oral-only drugs: Certain oral medications not yet transitioned to the bundle (CMS has delayed the oral drug bundle transition multiple times)
- Vaccines: Influenza (90686), Hepatitis B (90747), Pneumococcal (90732)—billed separately under Part B
- Non-renal conditions: Services for conditions unrelated to renal failure (e.g., an orthopedic procedure, an acute infection unrelated to dialysis care)
- AKI dialysis: Patients receiving dialysis for acute kidney injury who have not reached ESRD status are billed fee-for-service under CPT 90935–90940 and are NOT subject to the ESRD PPS bundle
The ESRD vs. AKI Distinction: Where Most Billing Errors Begin
The ICD-10 distinction between AKI and ESRD is the most consequential coding decision in nephrology billing. The applicable payment rules differ entirely:
| Condition | ICD-10 | Payment Model | EPO Billable Separately? |
|---|---|---|---|
| Acute Kidney Injury (AKI) | N17.0–N17.9 | Fee-for-service | Yes (with Hgb <10 g/dL per LCD L33822) |
| CKD Stage 5 (pre-dialysis) | N18.5 | Fee-for-service | Yes (with LCD L33822 documentation) |
| ESRD (on dialysis) | N18.6 | PPS bundled rate | No — bundled in composite rate |
An EMR that defaults all dialysis patients to N18.6 (ESRD) status will cause: (1) revenue loss on AKI claims that should be billed fee-for-service at higher rates, and (2) compliance exposure from appearing to bill bundled items separately for ESRD patients. Medsure RCS performs an ESRD/AKI status validation on every dialysis charge before submission.
ESRD QIP: The 2% Payment Risk Most Practices Underestimate
The ESRD Quality Incentive Program (QIP), established under Section 153(c) of MIPPA, reduces Medicare payments by up to 2% for dialysis facilities that fail quality reporting requirements. A 100-patient ESRD panel generating $180,000 in annual capitation faces a $3,600 payment reduction—plus the administrative cost of remediation. QIP measures for 2026 include:
- Kt/V adequacy rate (target: ≥1.2 for ≥97% of patients)
- Hypercalcemia rate (serum calcium >10.2 mg/dL)
- Long-term catheter rate (minimize central venous catheters as access)
- NHSN bloodstream infection reporting (mandatory surveillance)
- Vascular access monitoring and patient safety measures
- Patient experience of care (ICH-CAHPS survey results)
All QIP data is submitted via CROWNWeb—the CMS dialysis data collection portal. Non-submission equals non-compliance. Our ESRD quality reporting compliance service monitors CROWNWeb submission timelines and QIP measure documentation for enrolled Florida practices.
Nephrology CPT Code Reference 2026
The table below covers the primary CPT code families used in nephrology physician billing. For a complete reference including HCPCS J-codes, ICD-10 diagnosis codes, and documentation requirements by payer, see our nephrology CPT codes 2026 guide.
View Complete CPT Code Reference — 14 codes with payment type and documentation requirements
| CPT / HCPCS | Description | Payment Type | Key Documentation Requirement |
|---|---|---|---|
| 90935 | Hemodialysis procedure, with single physician evaluation | FFS (AKI) or bundled (ESRD) | ESRD vs. AKI status; separate physician evaluation note |
| 90937 | Hemodialysis procedure, with repeated evaluations, same day | FFS or bundled | Separate evaluation note for each physician contact |
| 90940 | Hemodialysis with procedure (e.g., vascular access intervention) | FFS | Procedure report; access type (fistula, graft, catheter) |
| 90945 | Peritoneal dialysis, with single physician evaluation | FFS or MCP | PD modality confirmed; solution and dwell time documented |
| 90947 | Peritoneal dialysis, with repeated evaluations, same day | FFS or MCP | Multiple evaluation notes on same date of service |
| 90951 | ESRD MCP, patient age ≤19, 4+ visits/month, in-center | Capitation (monthly) | Age ≤19 verified; minimum 4 documented contacts/month |
| 90959 | ESRD MCP, patient age ≥20, 4+ visits/month, in-center | Capitation (monthly) | Minimum 4 documented in-center visits/month |
| 90962 | ESRD MCP, patient age ≥20, 1–2 visits/month, in-center | Capitation (monthly) | 1–2 visits documented; clinical rationale for reduced frequency |
| 90963 | ESRD MCP, patient age ≥20, home dialysis, 4+ visits/month | Capitation (monthly) | Home modality confirmed; 4+ home contacts/month documented |
| 90966 | ESRD MCP, patient age ≥20, home dialysis, 1–2 visits/month | Capitation (monthly) | Home dialysis; 1–2 monthly contacts documented |
| 90989 | Dialysis training, completed course (patient/caregiver) | FFS | Training log; session dates; competency assessment signed |
| 90993 | Dialysis training, per session | FFS | Each session note; topics covered; patient response |
| 50360 | Renal transplant, cadaveric donor, recipient operation | FFS (90-day global) | UNOS center certification; CMS 2728 post-transplant update |
| 50365 | Renal transplant, living donor, recipient operation | FFS (90-day global) | Living donor workup; UNOS listing documentation |
| 99213–99215 | Office E&M, established patient (low/moderate/high complexity) | FFS | CKD stage in ICD-10; MDM complexity documented (99215 = high) |
| 99490 | Chronic Care Management, 20 minutes/month | FFS (monthly) | Written care plan; patient consent; 20 min clinical staff time |
| 99491 | CCM, 30 min/month, performed by physician | FFS (monthly) | Physician directly performs and documents 30 min |
| J0885 | Epoetin alfa (EPO), per 1,000 units | FFS — non-ESRD patients only | Hgb <10 g/dL at time of order; LCD L33822 compliance; NOT billable for ESRD patients |
| J0886 | Epoetin beta (Mircera), per 1 mcg | FFS — non-ESRD patients only | Hgb <10 g/dL; prior auth required by most commercial payers |
Top Nephrology Claim Denials and How to Resolve Them
Five denial patterns account for over 90% of nephrology claim rejections. The strategies to reduce nephrology claim denials are specific to each root cause. Generic denial workflows do not work for ESRD billing—each pattern requires a different resolution path.
Denial 1 — ESRD PPS Bundling Errors (41% of nephrology denials)
Root cause: Services included in the ESRD PPS composite rate—saline, heparin, epoetin alfa (J0885), routine dialysis labs, IV iron (J1756/J1439), vascular access management—billed as separate line items for confirmed ESRD patients.
Why it happens: Staff apply fee-for-service billing templates to ESRD patients, or an EMR system fails to suppress bundled charges when ESRD status is active.
Resolution — denied claims:
- Submit a corrected claim (not a formal appeal) removing all bundled service line items. The original composite rate claim stands; only the separately billed items need to be voided.
- If the composite rate claim was not billed, submit it with the correct date of service.
- Document the corrective action in the patient account for audit trail purposes.
Prevention: Build an EMR charge suppression rule that blocks all CPT/HCPCS codes on the ESRD bundled drug and service list when patient ESRD status flag is active. Medsure RCS validates ESRD status at charge entry before submission.
Show 4 More Denial Patterns — Frequency, Form 2728, Home Dialysis Training & ESA Dosing (23%–18% of denials each)
Denial 2 — Dialysis Frequency Exceeds LCD Policy (23% of nephrology denials)
Root cause: Billing for more than three hemodialysis sessions per week without documented medical necessity for higher frequency. Medicare LCD L34029 (Renal Dialysis) establishes three sessions per week as standard; four or more per week requires documented clinical justification.
Resolution — denied claims:
- Obtain the physician's clinical rationale for increased frequency (e.g., persistent fluid overload, hyperkalemia requiring urgent sessions, acute decompensation).
- Resubmit with modifier KX on the claim to attest that LCD requirements are met.
- Attach the clinical documentation to the appeal if payer requires it.
Prevention: Build a frequency alert into the scheduling system that flags any patient scheduled for 4+ HD sessions/week and requires a signed physician order with clinical rationale before the session is authorized.
Denial 3 — Missing CMS Form 2728 / ESRD Network Certification (18% of nephrology denials)
Root cause: The CMS Medical Evidence Report (Form 2728) was not submitted to ESRD Network 7 within 30 days of ESRD initiation, or cannot be produced during a Medicare audit. Without a current Form 2728 on file, Medicare cannot confirm ESRD entitlement and will deny all ESRD claims for that patient.
Resolution — denied claims:
- Retroactively complete and submit Form 2728 to Network 7. Obtain confirmation of the submission date and Network case number.
- Resubmit denied claims with documentation of the Form 2728 submission and confirmation number.
- For Medicare: initiate a Redetermination request (60-day window from denial) with Form 2728 confirmation attached.
Prevention: Maintain a Form 2728 tracking log for every active ESRD patient with submission date, Network confirmation number, and annual review date. Conduct an annual audit to confirm all active ESRD patients have a current Form 2728 on file.
Denial 4 — Home Dialysis Training Documentation Incomplete (18% of nephrology denials)
Root cause: Home dialysis training claims (CPT 90989, 90993) denied because the training log, competency verification, or supply delivery confirmation is absent. CMS requires documented evidence of patient and/or caregiver competency before home dialysis initiation.
Resolution — denied claims:
- Compile the complete training record: session-by-session notes with dates, duration, topics, and patient response.
- Attach the competency assessment form signed by both the training nurse and the patient or caregiver.
- Submit a formal appeal with the training documentation and the physician's order for home dialysis.
Prevention: Implement a standardized training checklist that creates a session-by-session audit trail. No home dialysis training claim should be submitted without a completed training log and a signed competency assessment form in the chart.
Denial 5 — ESA/EPO Dosing Outside LCD L33822 Requirements
Root cause: Epoetin alfa (J0885) claims denied because hemoglobin (Hgb) was not documented at <10 g/dL at the time of ESA initiation, or because dose escalation was not supported by a documented 4-week treatment response evaluation. LCD L33822 mandates Hgb <10 g/dL to initiate ESA therapy.
Note: This denial only applies to non-ESRD patients. For ESRD patients, EPO is bundled in the PPS composite rate and must not be billed separately—separate billing for ESRD patients falls under Denial 1 above.
Resolution — denied claims:
- Obtain the lab report confirming Hgb <10 g/dL with the date of test.
- For dose escalation denials: document the 4-week response evaluation with current Hgb and the physician’s clinical reasoning for dose adjustment.
- Submit a Redetermination with the lab documentation and LCD L33822 initiation criteria cited in the cover letter.
Prevention: Add a pre-authorization step to the EPO ordering workflow that requires a current Hgb lab result (within 14 days) before the order is finalized. This prevents billing before documentation exists.
For a complete denial management program including medical necessity appeals, see our nephrology denial management and nephrology medical necessity appeals service pages.
Medicare ESRD Rules That Directly Affect Your Revenue
Our Medicare ESRD billing specialists apply the following CMS regulations in daily billing operations for Florida nephrology practices.
View Medicare ESRD Regulatory Details — 4 key CMS regulations affecting Florida practices
42 CFR 413.170–413.235 — ESRD PPS Core Regulations
Defines the composite rate structure, bundled items list, and payment adjustments. Florida facilities should confirm they are claiming all applicable adjustments including the low-volume adjustment (facilities performing fewer than 4,000 treatments annually) and the correct wage index for their county. Missing the low-volume adjustment alone can reduce annual reimbursement by $20,000–$45,000 for small practices.
CMS Home First Initiative — Advancing American Kidney Health (AAKH)
CMS is actively incentivizing home dialysis. Florida home dialysis is growing at 25% annually. Key billing implications for expanding programs:
- Home MCP codes: 90963–90966 (select by visit frequency and patient age)
- Training codes: 90989 (complete course), 90993 (per session) — require session-level documentation
- Payment model: ESRD Treatment Choices (ETC) mandatory model adjusts payment rates for facilities with low home modality rates
See our peritoneal dialysis billing reference for full PD-specific coding guidance.
Consolidated Billing Rule — Supplier Liability
Under ESRD PPS consolidated billing, the CMS-certified dialysis facility—not the external supplier—is responsible for billing all bundled items. A supplier who bills Medicare separately violates the rule. Applies to:
- Dialysis supply companies
- Pharmacy vendors billing EPO directly
- Lab vendors billing routine dialysis labs
Medsure RCS reviews all vendor billing relationships for consolidated billing compliance.
OIG Work Plan — ESA/EPO High-Priority Oversight
The HHS OIG consistently flags EPO/ESA billing as a high-priority oversight target. RAC auditors focus on three specific patterns:
- EPO/J0885 billed separately for ESRD patients (should be bundled)
- EPO dosing above LCD L33822 Hgb threshold limits
- Dialysis billed without active ESRD Network 7 certification on file
Our nephrology billing audit preparation guide covers the full RAC and OIG risk profile for Florida practices.
Nephrology Billing in Florida: Market Context and Payer Mix
Florida has the 4th highest ESRD prevalence rate in the United States—driven by its large elderly population, high rates of Type 2 diabetes, and significant Caribbean and Latin American diaspora communities with elevated CKD risk. For a complete Florida-specific analysis, see our nephrology billing Florida service page.
Florida ESRD Market Overview
- ESRD Network 7: All Florida dialysis facilities operate under ESRD Network 7, which provides oversight, CROWNWeb technical assistance, and quality improvement support. Network 7 is also the first point of contact for Form 2728 certification issues.
- Major dialysis operators: DaVita (120+ centers in Florida), Fresenius Medical Care (100+ centers), and US Renal Care operate the majority of Florida dialysis facilities. Physician billing in these centers must align with the facility's consolidated billing arrangements.
- Medicare dominance: 80%+ of Florida nephrology revenue is Medicare or Medicare Advantage. The state's high concentration of retirees means a higher-than-national-average share of Medicare Advantage enrollment—particularly Humana MA and WellCare—which apply their own prior auth requirements on top of Medicare coverage rules.
- Medicaid managed care (SMMC): Florida Medicaid for ESRD patients runs through the Statewide Medicaid Managed Care program. Primary plans include Sunshine Health, Molina Healthcare, and Humana Florida Medicaid. SMMC ESRD rates are significantly lower than Medicare composite rates and require separate credentialing and prior auth workflows.
Tampa Bay Nephrology Market
Hillsborough County has approximately 4,200 ESRD patients. Major nephrology groups include BayCare Kidney Care, Tampa General Hospital Nephrology, Florida Kidney Physicians, and Renal Associates of Tampa Bay. DaVita and Fresenius each operate 15+ dialysis centers in the county.
Medsure RCS provides nephrology billing Tampa services to Hillsborough County practices, with established workflows for Sunshine Health and Humana Florida Medicaid managed care authorization processes specific to this market.
Orlando Nephrology Market
Orange County (Orlando) has approximately 3,800 ESRD patients. Key groups include AdventHealth Nephrology, Orlando Health Kidney Specialists, and UCF Health's expanding CKD management program. The growing Puerto Rican diaspora in the metro drives Type 2 DM rates—and downstream CKD/ESRD incidence—above statewide averages.
Our nephrology billing Orlando services support Orange County practices navigating Florida Blue and Molina Healthcare Medicaid, which dominate this market's Medicaid managed care segment.
Florida Nephrology Payer Reference
View Florida Payer Reference Table — 6 payers with revenue share and nephrology billing specifics
| Payer | Type | Revenue Share | Key Nephrology Considerations |
|---|---|---|---|
| Medicare Part B (CGS, J15) | Traditional Medicare | ~65% | ESRD PPS applies; MAC is CGS Jurisdiction 15 for FL; QIP compliance required; CROWNWeb data submission monthly |
| Humana Medicare Advantage | Medicare Advantage | ~10% | Prior auth required for home dialysis initiation, ESA therapy; own formulary for injectable drugs; Medicare ESRD PPS still applies |
| WellCare Medicare Advantage | Medicare Advantage | ~5% | Prior auth for transplant evaluation; active in both MA and FL Medicaid managed care; separate credentialing required |
| Sunshine Health (FL Medicaid SMMC) | Medicaid Managed Care | ~5% | Prior auth for ESA therapy, transplant evaluation; lower ESRD rates than Medicare; Navinet/Availity portal |
| Molina Healthcare (FL) | Medicaid Managed Care | ~4% | Dominant in Orange County (Orlando); separate credentialing portal; prior auth for home dialysis and ESA |
| Florida Blue / BCBS FL | Commercial | ~6% | Prior auth for home dialysis, ESA, kidney transplant evaluation; 90-day global period rules apply for transplant billing |
Florida has the 4th highest ESRD prevalence rate in the US — and most nephrology practices here are still leaving recoverable revenue on the table through bundling errors and missed capitation codes.
Why Nephrology Practices Choose Medsure RCS
Certified Nephrology Billing Expertise
Our billing team includes Certified Professional Coders (CPC) with nephrology specialty certification from the AAPC. We apply ASN (American Society of Nephrology) billing guidance, CMS ESRD regulations (42 CFR 413), and ESRD Network 7 technical bulletins in our daily work—not generic billing guidelines adapted for nephrology.
ESRD-Specific Billing Workflows
We maintain separate ESRD and non-ESRD billing workflows with automated ESRD status validation at charge entry. CMS Form 2728 tracking, CROWNWeb submission monitoring, QIP measure documentation review, and consolidated billing compliance checks are built into our monthly billing cycle for every enrolled practice.
Performance Benchmarks We Report Against
- Net Collection Rate (NCR): >94% for Medicare-heavy nephrology mix
- Days in Accounts Receivable: <38 days
- ESRD capitation collection rate: 99%+ (Medicare auto-payment)
- First-pass claim acceptance rate: >96%
- Clean claim rate: >98%
We report monthly against MGMA nephrology benchmarks—not internally defined metrics.
Florida-Local Payer Knowledge
We know the Florida nephrology market: ESRD Network 7 requirements, CGS MAC billing rules, Sunshine Health and Molina Medicaid auth workflows, and the specific payer mix dynamics in Tampa, Orlando, St. Petersburg, and Jacksonville. Our team provides nephrology billing Florida services with local payer expertise built into the standard billing workflow.
Evaluating whether to keep nephrology billing in-house or outsource it? Our outsourced nephrology billing comparison covers the full cost analysis, ESRD complexity factors specific to Florida, and our recommended hybrid model for practices managing both ESRD capitation and non-ESRD fee-for-service revenue streams.
Frequently Asked Questions — Nephrology Billing
What CPT codes are used for nephrology billing?
Nephrology billing spans five CPT code families:
- Hemodialysis: 90935–90940
- Peritoneal dialysis: 90945–90947
- ESRD Monthly Capitation Payments: 90951–90970
- Kidney transplant: 50300–50380
- E&M (office/inpatient): 99202–99215
ESAs (J0885, J0886) are billed separately for non-ESRD patients only—EPO is bundled in the ESRD PPS composite rate for ESRD patients. See our full nephrology CPT codes 2026 reference.
View 6 More FAQs — ESRD PPS, claim denials, Medicare coverage, QIP, credentialing & outsourcing
What is the ESRD Prospective Payment System (PPS) and how does it affect billing?
The ESRD PPS (42 CFR 413.170–413.235) packages 150+ dialysis-related items into a single composite rate—$261.41 per treatment in 2026 for most facilities. Billing any bundled item separately for an ESRD patient triggers automatic denial.
Key rule: AKI (acute kidney injury) dialysis is not subject to the PPS bundle and is billed fee-for-service. The ESRD/AKI distinction at charge entry is the most consequential billing decision in nephrology.
What is the most common reason for nephrology claim denials?
ESRD PPS bundling errors account for 41% of nephrology denials—billing saline, heparin, EPO, or other PPS-bundled services separately for ESRD patients. Dialysis frequency documentation errors (23%), missing CMS Form 2728 or ESRD Network certification (18%), and home dialysis training documentation issues (18%) follow in frequency. See our nephrology denial management page for full resolution workflows.
Does Medicare cover nephrology services in Florida?
Yes. Medicare covers 80%+ of nephrology revenue for most Florida practices. All ESRD patients qualify for Medicare regardless of age under 42 U.S.C. §426A. The Medicare Administrative Contractor for most Florida ESRD claims is CGS (Jurisdiction 15). Florida is part of ESRD Network 7, which oversees facility certification and CROWNWeb reporting for all Florida dialysis centers.
Can the ESRD Quality Incentive Program (QIP) reduce my Medicare payments?
Yes—by up to 2%. The ESRD QIP reduces Medicare payments for dialysis facilities that fail quality reporting requirements. Key measures include Kt/V adequacy (≥1.2), hypercalcemia rate, catheter minimization, NHSN infection reporting, and vascular access monitoring. All data is submitted monthly via CROWNWeb. Our ESRD quality reporting compliance service monitors these submissions for Florida practices.
Do Florida nephrology practices need special credentialing for ESRD billing?
Yes. Two requirements apply:
- ESRD facility certification: CMS-certified status and ESRD Network 7 enrollment required to bill Medicare for ESRD services
- CMS Form 2728: Must be completed and submitted to Network 7 within 30 days of ESRD initiation for every new patient — missing Form 2728 is one of the top-three nephrology denial causes and can retroactively void all claims for that patient
Can nephrology billing be outsourced in Florida?
Yes. Most Florida practices use a hybrid model: manage ESRD capitation internally (predictable monthly auto-payment) and outsource the non-ESRD fee-for-service work:
- AKI dialysis fee-for-service claims
- CKD office visit billing and CCM capture
- Kidney transplant global period billing
- Denial management and CROWNWeb compliance monitoring
See our outsourced nephrology billing comparison for a full cost analysis.
Start With a Free Nephrology Billing Review
We review your current ESRD claim denial rate, MCP coding accuracy, QIP documentation posture, and Form 2728 compliance—at no charge. Practices typically identify $40,000–$180,000 in recoverable revenue during the first 90-day review period.
Medsure RCS • St. Petersburg, FL • Serving nephrology practices across Tampa Bay, Orlando, and all of Florida