The number of people with end-stage renal disease (ESRD) grew by 31.3% between 2002 and 2022. But what really adds to the predicament is that billing for ESRD care is complicated. Healthcare providers frequently experience denied claims, delayed reimbursement, and financial loss due to the complex billing and compliance requirements. Let’s not worry, though.
Our guide holds the solution! Before using CPT code 90966 in your nephrology claims, read this guide, as it includes all the information you require for clean claim submissions.
CPT Code 90966 – Description
Let’s grasp the ESRD before we comprehend the code!
The last stage of chronic kidney disease (CKD), known as end-stage renal disease (ESRD), is when the kidneys fail and are unable to sustain the body, necessitating dialysis or a kidney transplant to survive. Patients with this condition can get dialysis at home instead of in a hospital or dialysis facility.
To bill physician services related to home dialysis, you can use CPT code 90966. This code refers to a physician visit or routine maintenance where the provider oversees the care plan and offers assessment and counseling to a patient with ESRD, who is 20 years of age or older, receiving home dialysis for a whole month.
Note that the reimbursement for this code is a capitation payment. So, the payments for all services provided in a month are bundled into one amount.
Scenarios Where CPT Code 90966 is Applicable
The following two real-life examples will help you better understand the description of CPT code 90966.
Regular Monthly Checkup
Suppose a 45-year-old patient requires dialysis 3 to 5 times a week because his chronic disease has escalated towards ESRD. So, the physician meets the patient periodically (typically once a month) to manage the care plan. During these visits, the physician assesses the patient’s condition, revises the care plan (if needed), and counsels the patient. Since the patient is an adult and has received routine ESRD maintenance for a month, CPT code 90966 is used.
Change in Home Dialysis Routine
Suppose a 50-year-old patient recently had changes made to his dialysis schedule and fluid amount. Because the patient noticed swelling in his legs, his blood test revealed extra fluid in his body. So the physician changes the amount of dialysis fluid. To avoid any further issues, the physician keeps a keen eye on the progress of the patient’s condition. So he visits him a couple of times a month to ensure everything is going well. Since the physician is visiting the patient for home dialysis, he can bill his services after a month with CPT code 90966.
Applicable Modifiers for CPT Code 90966
Here are some modifiers that are usually appended to code 90966.
Modifier 95
Modifier 95 is a telehealth modifier. It indicates that the service was rendered via a real-time, interactive audio and video telehealth system. It should be used with CPT code 90966 for virtual services, depending on payer rules. So, if the physician managed the patient’s home dialysis routine through an interactive virtual platform, modifier 95 should be applied to the code.
Modifier GT
Similarly, modifier GT explains that service was delivered via a synchronous audio/visual telehealth system, which is essentially the same as modifier 95. However, some private payers still prefer its use over 95 for a clear distinction between telehealth and in-person visits.
CPT Code 90966 – Billing & Reimbursement Guidelines
This section will save you from receiving denials for CPT code 90966 claims. So pay extra attention to these billing and reimbursement guidelines.
Include Detailed Documentation
These are some essential pointers of information that must be mentioned in your paperwork.
- Written proof that the patient was trained to perform dialysis in the home environment.
- Mention the method used (e.g., hemodialysis or peritoneal dialysis).
- Frequency of dialysis.
- Patient tolerance of dialysis sessions.
- The amount of dialysis fluid.
- Any changes made to the care plan.
- Details and results of any tests performed.
- Clinical/counseling notes.
- Signed physician/non-physician practitioner order.
Comply with the Rules of Insurance Payers
The reimbursement rules and billing policies vary across insurance payers. For example, Medicare no longer accepts the GT modifier for telehealth services. Instead, it relies on a place of service (POS) code 02 for the billing of evaluation and management (E/M) services. For professional claims, the modifier 95 typically replaces the GT modifier, though some private payers may still use it for institutional claims.
Therefore, you must make sure that your claims fully comply with the payer’s policies before submission.
Avoid Incorrect Use of 90966
Although we have discussed above how to use CPT code 90966 correctly, the following are some circumstances to keep in mind where you cannot bill this code.
- The first and foremost is that if the patient receives home dialysis for less than a month, you will bill the half service with other codes.
- This code only represents home dialysis services. You cannot charge this code for an in-facility dialysis.
- The code is specifically for patients 20 years of age or older. Services for patients younger than 20 will not be billed with 90966. Other codes apply in that case, such as 90963 to 90965.
Final Word
CPT code 90966 covers home dialysis services for patients 20 years of age or older for a period of one month. This code’s description accurately reflects our scenarios. It is a telemedicine-approved code. Therefore, modifier 95 and GT are applicable.
Even though we tried to cover all the essential billing rules and guidelines related to this code, it is possible that we overlooked a case that is troubling you. Hence, we strongly advise you to seek expert counsel. MediBillMD’s skilled billers offer expert nephrology billing services at affordable rates. Consider reaching out to them to streamline your insurance billing.
