Medical practitioners around the United States are obligated to provide undisturbed care to their patients. Rehabilitation experts require a specific set of Inpatient and Outpatient programs to provide top-of-the-line care to their patients. Dialysis providers require a specific End-stage Renal Disease (ESRD) billing service, as it can be a hassle for the administrative staff. 

ESRD Billing Service involves Medicare’s Prospective Payment System (PPS), covering several treatments, drugs, labs, and supplies.

Alongside the complexities, ESRD demands to stay updated with a range of core details, compliance standards, coding essentials, and document requirements. The following blog covers all the details, offering you a streamlined Do’s and Don’t’s to avoid any complications.

 

Foundation of ESRD Billing Services 

 

It is crucial to understand certain facilities bills that are addressed for most items like drugs and labs, also called consolidated billing. The medical providers are strictly required to use correct CPT/HCPCS codes and handle Monthly Capitation Payments (MCPs) for physicians. 

All this adherence often wears off the actual patient-care and becomes a hefty task for the administrative staff. Since many clinicians are more familiar with the traditional billing procedures, ESRD Billing can be a real deal. However, it is crucial to identify the difference between the two.

ESRD billing: The paperwork is more detailed, and you need to track treatments differently. Most ESRD patients use Medicare, which changes how you handle claims and payments. Medicare rules affect almost everything in kidney care billing.

The ESRD payment system bundles services

Medicare pays one fixed amount for all dialysis-related services and drugs. This includes lab work and medications given during treatment. Clinics get monthly payments instead of billing for each service. The payment amount changes based on patient needs and location.

 

Compliance Standards in ESRD Billing Services 

 

Medicare Certification for ESRD Billing Services

Dialysis centers need Medicare’s approval before they can bill for ESRD services and get paid. To get certified, your facility has to follow the health and safety rules set up by Medicare and Medicaid. These rules aren’t suggestions – they’re must-follow standards. If your center isn’t certified or lets the certification lapse, Medicare won’t pay for any dialysis treatments. It’s really the first step you need to take care of if you want to run a dialysis center and get reimbursed for your work.

Provider Enrollment Necessities

Before sending any bills, providers have to sign up through PECOS. You’ll need to tell them where your practice is, who owns it, and show your licenses. Keep in mind – if anything changes with your facility, like new owners or moving to a different location, you have to let them know within 30 days. Don’t forget to keep your enrollment up to date, or you might run into billing problems. It’s pretty straightforward but important to get right the first time.

National Provider Identifier Requirements

Every dialysis facility and individual provider must maintain a valid National Provider Identifier (NPI) for claim processing. The NPI serves as the unique identification number used across all ESRD billing services transactions. Both Type 1 (individual) and Type 2 (organizational) NPIs may be required depending on your facility structure.

2026 Regulatory Updates Impacting ESRD Billing Services

The 2026 payment year introduces updated QIP measures and revised documentation requirements for home dialysis modalities. CMS has also implemented stricter audit protocols for separately billable items and expanded telehealth billing options for nephrology services.

 

Coding Essentials for ESRD Billing Services 

 

ICD-10 Diagnosis Codes in ESRD Billing Services

 

N18.6 End Stage Renal Disease (Primary Diagnosis)
N18.5 Chronic Kidney Disease, Stage 5
Z99.2 Dependence on Renal Dialysis
I12.0 Hypertensive Chronic Kidney Disease With Stage 5 or ESRD
E11.22 Type 2 Diabetes mellitus with Diabetic Chronic Kidney Disease

 

CPT Procedure Codes for Dialysis Treatments

 

90935 Hemodialysis procedure with single physician evaluation
90937 Hemodialysis procedure with repeated evaluations
90945/90947 Dialysis procedure other than hemodialysis
90951-90962 End-stage renal disease-related services
90993-90999 Home dialysis services

 

Required Modifiers in ESRD Billing Services

 

AV modifier Item furnished in conjunction with a prosthetic device
G-modifiers (GA, GB, GC, GD, GE, GF, GG) Used for URR
CD modifier AMCC test has been ordered by an ESRD facility
CE modifier AMCC test has been ordered by physician not part of ESRD facility
AX modifier Item furnished in conjunction with dialysis services
EM modifier Emergency reserve supply
BO modifier Orally administered nutrition

 

Documentation Requirements in ESRD Billing Services 

 

ESRD Billing focuses more on compliance and expects the patient’s medical records to show the need for services prescribed to them. It is important for the providers to ensure they receive the required documents to avoid any disruption while claiming the offered services. 

  • Legible signatures of the physician or service provider (Handwritten and/or Electronic)
  • Date of Service (If applicable)
  • Lab reports related to the drug administered
  • Clinician’s name and credentials. Notes used for medication by the clinician or nurse.
  • Dialysis treatment record including start/ stop times, rate/ volume/ flow rate, and vital signs.
  • Documented record of the patient’s condition before, during, and after the billing period.

Common Mistakes in ESRD Billing Services 

Service Bundling Errors Affecting Revenue

Providers often incorrectly bill separately for services included in the composite rate or fail to bill for legitimately separate items like ESAs and IV iron, leading to compliance issues and lost revenue.

Modifier Misuse in Claims

Missing required modifiers, such as G-modifiers for adequacy measurements or AV modifiers for dialysis-related items, triggers automatic claim denials and payment delays.

Insufficient Documentation Issues

Incomplete medical necessity documentation, particularly for separately billable drugs and biologicals, remains a primary cause of denials and adverse audit findings.

Payer Coordination Failures

Incorrectly coordinating benefits between Medicare, secondary insurers, and Medicare Advantage plans leads to payment delays and potential overpayment recovery demands.

 

Master ESRD Billing for Boosted Revenue

 

Conclusion

Mastering ESRD billing services is essential for maintaining financial stability and regulatory compliance in today’s complex healthcare environment. Implementing proper coding, documentation, and claim submission practices optimizes your revenue cycle while minimizing denials. As 2026 brings new regulatory updates and quality measures, staying informed and adapting your billing processes ensures your facility remains compliant and financially successful.

Team up with trusted Utah Billing Services to ensure accurate medical coding and faster reimbursement. Learn how to make your billing easier and earn more money today!

Frequently Asked Questions

Q: What is consolidated billing in ESRD services? 

A: Consolidated billing means the dialysis facility bills Medicare for most items, including drugs, labs, and supplies, under a single bundled payment.

Q: Why is the National Provider Identifier (NPI) required for ESRD billing? 

A: The NPI serves as your unique identification number for processing all ESRD billing transactions with Medicare and other payers.

Q: What happens if I miss the Medicare timely filing deadline for ESRD claims? 

A: Missing the 12-month filing deadline results in permanent loss of reimbursement for those treatments with no opportunity for resubmission.

Q: Which medications are separately billable outside the ESRD composite rate? 

A: ESAs, IV iron, IV vitamin D analogs, calcimimetics, and phosphate binders can be billed separately when medically necessary and documented.