{"id":6468,"date":"2026-05-14T14:34:14","date_gmt":"2026-05-14T14:34:14","guid":{"rendered":"https:\/\/medibillmd.com\/blog\/?p=6468"},"modified":"2026-05-14T14:34:41","modified_gmt":"2026-05-14T14:34:41","slug":"cpt-code-90960","status":"publish","type":"post","link":"https:\/\/medibillmd.com\/blog\/cpt-code-90960\/","title":{"rendered":"Ultimate Guide to CPT Code 90960"},"content":{"rendered":"\n<p>Suppose a nephrology practice wraps up a month of dialysis management for a patient with end-stage renal disease (ESRD). It was a good month, and treatment went well. The physician performed 4 face-to-face consultations with the patient during the month. The care was thorough. The documentation was complete. The billing department submitted the claim with CPT code 90960 to bill the ESRD services. But, some days later, the claim was returned with a denial code. The reason? A minor mistake related to the monthly capitation payment (MCP) rules.<\/p>\n\n\n\n<p>Many nephrology practices encounter this issue. That is why we put together this complete guide to explain what 90960 actually is, when to use it, which modifiers to apply, and what documentation and billing guidelines you must follow. So, let\u2019s start.&nbsp;<\/p>\n\n\n\t\t\t\t<div class=\"wp-block-uagb-table-of-contents uagb-toc__align-left uagb-toc__columns-1 uagb-toc__collapse uagb-block-4df14e8d      \"\n\t\t\t\t\tdata-scroll= \"1\"\n\t\t\t\t\tdata-offset= \"30\"\n\t\t\t\t\tstyle=\"\"\n\t\t\t\t>\n\t\t\t\t<div class=\"uagb-toc__wrap\">\n\t\t\t\t\t\t<div class=\"uagb-toc__title\">\n\t\t\t\t\t\t\tTable Of Contents\t\t\t\t\t\t\t\t\t\t\t\t\t<svg xmlns=\"https:\/\/www.w3.org\/2000\/svg\" viewBox= \"0 0 384 512\"><path d=\"M192 384c-8.188 0-16.38-3.125-22.62-9.375l-160-160c-12.5-12.5-12.5-32.75 0-45.25s32.75-12.5 45.25 0L192 306.8l137.4-137.4c12.5-12.5 32.75-12.5 45.25 0s12.5 32.75 0 45.25l-160 160C208.4 380.9 200.2 384 192 384z\"><\/path><\/svg>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"uagb-toc__list-wrap \">\n\t\t\t\t\t\t<ol class=\"uagb-toc__list\"><li class=\"uagb-toc__list\"><a href=\"#cpt-code-90960-description\" class=\"uagb-toc-link__trigger\">CPT Code 90960 \u2013 Description<\/a><li class=\"uagb-toc__list\"><a href=\"#scenarios-where-cpt-code-90960-is-applicable\" class=\"uagb-toc-link__trigger\">Scenarios Where CPT Code 90960 is Applicable<\/a><ul class=\"uagb-toc__list\"><li class=\"uagb-toc__list\"><a href=\"#chronic-kidney-disease-ckd\" class=\"uagb-toc-link__trigger\">Chronic Kidney Disease (CKD)<\/a><li class=\"uagb-toc__list\"><li class=\"uagb-toc__list\"><a href=\"#esrd-patient-with-complicating-cardiovascular-conditions\" class=\"uagb-toc-link__trigger\">ESRD Patient with Complicating Cardiovascular Conditions<\/a><\/li><\/ul><\/li><li class=\"uagb-toc__list\"><a href=\"#applicable-modifiers-for-cpt-code-90960\" class=\"uagb-toc-link__trigger\">Applicable Modifiers for CPT Code 90960<\/a><li class=\"uagb-toc__list\"><a href=\"#cpt-code-90960-billing-reimbursement-guidelines\" class=\"uagb-toc-link__trigger\">CPT Code 90960 \u2013 Billing &amp; Reimbursement Guidelines<\/a><ul class=\"uagb-toc__list\"><li class=\"uagb-toc__list\"><a href=\"#one-mcp-code-per-calendar-month\" class=\"uagb-toc-link__trigger\">One MCP Code per Calendar Month<\/a><li class=\"uagb-toc__list\"><li class=\"uagb-toc__list\"><a href=\"#date-of-service-reporting\" class=\"uagb-toc-link__trigger\">Date of Service Reporting<\/a><li class=\"uagb-toc__list\"><li class=\"uagb-toc__list\"><a href=\"#documentation-requirements\" class=\"uagb-toc-link__trigger\">Documentation Requirements<\/a><li class=\"uagb-toc__list\"><li class=\"uagb-toc__list\"><a href=\"#medicare-reimbursement-rate\" class=\"uagb-toc-link__trigger\">Medicare Reimbursement Rate<\/a><\/li><\/ul><\/li><\/ul><\/li><li class=\"uagb-toc__list\"><a href=\"#wrapping-up\" class=\"uagb-toc-link__trigger\">Wrapping Up<\/a><\/ul><\/ul><\/ol>\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\n\n\n<div style=\"height:30px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>CPT Code 90960 <\/strong><strong>\u2013 Description<\/strong><\/h2>\n\n\n\n<p>CPT code 90960 is defined as:<\/p>\n\n\n\n<blockquote class=\"wp-block-quote is-style-plain has-ast-global-color-4-background-color has-background is-layout-flow wp-block-quote-is-layout-flow\">\n<p><strong><em>&#8220;End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 4 or more face-to-face visits by a physician or other qualified health care professional per month.&#8221;<\/em><\/strong><\/p>\n<\/blockquote>\n\n\n\n<p>90960 is a nephrology billing code. It basically serves as an MCP code. Meaning that it bundles all physician management services associated with the care of a patient diagnosed with ESRD over 30 days into a single payment.&nbsp;<\/p>\n\n\n\n<p>The essential thing to note here is that for CPT code 90960 to be valid, four conditions must be met:&nbsp;<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>The patient must be 20 years of age or older.<\/li>\n\n\n\n<li>The physician must have conducted four or more face-to-face visits.<\/li>\n\n\n\n<li>The physician must bill the payer once in a calendar month.\u00a0<\/li>\n\n\n\n<li>At least one of the visits must include a clinical examination of the vascular access site.<\/li>\n<\/ul>\n\n\n\n<p>Also, CPT code 90960 does not cover the dialysis procedures themselves. The following services are included in the scope of this code:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Establishment or updating of the patient&#8217;s dialysis plan.<\/li>\n\n\n\n<li>Outpatient management of all ESRD-related care.<\/li>\n\n\n\n<li>Medication management.<\/li>\n\n\n\n<li>Review of laboratory results and dialysis adequacy.<\/li>\n\n\n\n<li>Coordination of the patient&#8217;s overall treatment.<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Scenarios Where <\/strong><strong>CPT Code 90960<\/strong><strong> is Applicable<\/strong><\/h2>\n\n\n\n<p>To clearly understand when CPT code 90960 should be used, let\u2019s discuss a couple of real-world scenarios.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Chronic Kidney Disease (CKD)<\/strong><\/h3>\n\n\n\n<p>Suppose a patient comes to a nephrology clinic. He has been diagnosed with CKD stage 5. He is receiving in-center hemodialysis three times per week. His nephrologist conducts a complete monthly assessment at the beginning of the month. Reviews his dialysis adequacy labs, adjusts his weight targets, updates his medication, and revises his diet plan. Over the course of the month, the nephrologist provides three additional face-to-face evaluations.<\/p>\n\n\n\n<p>Since the nephrologist completed four or more face-to-face visits and performed the full monthly assessment, the billing team can submit CPT code 90960 to bill all the services.&nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>ESRD Patient with Complicating Cardiovascular Conditions<\/strong><\/h3>\n\n\n\n<p>Suppose a female patient presents to a nephrology practice. She has been on outpatient hemodialysis for several years and also carries diagnoses of congestive heart failure and anemia of CKD. Because of her complex clinical condition, the nephrologist sees her more frequently than the standard minimum.&nbsp;<\/p>\n\n\n\n<p>During the calendar month, the physician conducts a complete assessment, reviews her iron studies and erythropoiesis-stimulating agent (ESA) dosing, adjusts her volume management plan, and schedules her for four more face-to-face visits.<\/p>\n\n\n\n<p>This totals five face-to-face visits in the month, and a complete assessment has been performed. Hence, the billing department can report CPT code 90960 for the month with the appropriate ICD-10 codes.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Applicable Modifiers for <\/strong><strong>CPT Code 90960<\/strong><\/h2>\n\n\n\n<p>The following modifiers are commonly used with CPT code 90960:<\/p>\n\n\n\n<figure class=\"wp-block-table is-style-stripes\"><table><thead><tr><th class=\"has-text-align-center\" data-align=\"center\"><strong>Modifier<\/strong><\/th><th class=\"has-text-align-center\" data-align=\"center\"><strong>Short Description<\/strong><\/th><th class=\"has-text-align-center\" data-align=\"center\"><strong>Usage<\/strong><\/th><\/tr><\/thead><tbody><tr><td class=\"has-text-align-center\" data-align=\"center\"><a href=\"https:\/\/medibillmd.com\/blog\/q6-modifier\/\" target=\"_blank\" rel=\"noreferrer noopener\">Q6<\/a><\/td><td class=\"has-text-align-center\" data-align=\"center\">Locum Tenens Services<\/td><td class=\"has-text-align-center\" data-align=\"center\">This is used when the services are provided under a fee-for-time compensation arrangement by a substitute physician.<\/td><\/tr><tr><td class=\"has-text-align-center\" data-align=\"center\">GQ<\/td><td class=\"has-text-align-center\" data-align=\"center\">Telehealth Services<\/td><td class=\"has-text-align-center\" data-align=\"center\">Used to identify telehealth services rendered via an asynchronous (store-and-forward) telecommunications system.&nbsp;<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p><strong>Note:<\/strong> According to Medicare\u2019s Final <a href=\"https:\/\/www.cms.gov\/medicare\/coverage\/telehealth\/list-services\" target=\"_blank\" rel=\"noreferrer noopener nofollow\">List of Telehealth Services for 2026<\/a>, CPT code 90960 is a telehealth maintained code. Therefore, modifiers 93, 95, and GT are also applicable to the code, based on the payer\u2019s rules.\u00a0\u00a0<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>CPT Code 90960<\/strong><strong> \u2013 Billing &amp; Reimbursement Guidelines<\/strong><\/h2>\n\n\n\n<p>Here are some more essential guidelines that you need to know before using CPT code 90960 in your claims:<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>One MCP Code per Calendar Month<\/strong><\/h3>\n\n\n\n<p>Only one MCP code in the range 90951 through 90966 may be submitted per calendar month per patient, regardless of how many physicians are involved in the patient&#8217;s renal care.<\/p>\n\n\n\n<p>Even if a covering physician or non-physician practitioner (NPP) is involved in some of the face-to-face visits, the MCP physician who performed the complete assessment and established the plan of care is the one who submits the claim.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Date of Service Reporting<\/strong><\/h3>\n\n\n\n<p>CPT code 90960 must be submitted after the end of the calendar month, not during it. The date of service must span the full calendar month on a single detail line (e.g., from the first to the last day of the month). The days or units field should be submitted as one unit. Submitting a claim mid-month for a full-month code is a compliance error that will result in denial.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Documentation Requirements<\/strong><\/h3>\n\n\n\n<p>Detailed documentation is important if you want your claims to get reimbursed. Here is what\u2019s important for CPT code 90960 claims:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Documentation of the complete monthly assessment, including lab test reviews, dialysis adequacy assessment, medication changes, and care plan updates.<\/li>\n\n\n\n<li>Individual notes for each face-to-face visit conducted during the month, clearly dated and signed by the provider.<\/li>\n\n\n\n<li>The identity of the MCP physician responsible for overall care that month.<\/li>\n\n\n\n<li>ICD-10 codes that accurately reflect the patient&#8217;s diagnoses, with N18.6 (ESRD) as the primary diagnosis on all monthly ESRD management claims.<\/li>\n\n\n\n<li>Evidence of any co-management visits with other NPPs or covering physicians, including their credentials and dates of service.<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Medicare Reimbursement Rate<\/strong><\/h3>\n\n\n\n<p>According to the 2026 Medicare Physician Fee Schedule, the national average reimbursement rate for CPT code 90960 is $372.75, applicable in both facility and non-facility settings.<\/p>\n\n\n\n<p>However, this rate is the national average, and the actual amount varies for each Medicare Administrative Contractor (MAC) locality. Use the <a href=\"https:\/\/www.cms.gov\/medicare\/physician-fee-schedule\/search?Y=0&amp;T=4&amp;P=1&amp;HT=0&amp;CT=3&amp;H1=90960&amp;M=5\" target=\"_blank\" rel=\"noreferrer noopener nofollow\">PFS Lookup Tool<\/a> to confirm the current rate for your area before submitting claims.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Wrapping Up<\/strong><\/h2>\n\n\n\n<p>Let&#8217;s wrap up everything we have discussed.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>CPT code 90960 is used to bill MCP services delivered to ESRD patients, aged 20 or above, across 4 face-to-face sessions.\u00a0<\/li>\n\n\n\n<li>It bundles outpatient care coordination, medication management, lab test reviews, and treatment plan updates into a single monthly claim.<\/li>\n\n\n\n<li>Billing it correctly requires complete documentation and appropriate modifier usage (when necessary).\u00a0<\/li>\n<\/ul>\n\n\n\n<p>If your practice is finding CPT 90960 claims difficult to manage or if denial rates are climbing, an expert team can make a measurable difference. Consider MediBillMD&#8217;s <a href=\"https:\/\/medibillmd.com\/specialties\/nephrology-billing-services\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>nephrology billing services<\/strong><\/a> to keep your claims clean.<\/p>\n\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Suppose a nephrology practice wraps up a month of dialysis management for a patient with end-stage renal disease (ESRD). It [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":6469,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_eb_attr":"","content-type":"","_uag_custom_page_level_css":"","site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[10],"tags":[],"class_list":["post-6468","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-cpt-codes"],"uagb_featured_image_src":{"full":["https:\/\/medibillmd.com\/blog\/wp-content\/uploads\/2026\/05\/Ultimate-Guide-to-CPT-Code-90960-1.webp",1200,720,false],"thumbnail":["https:\/\/medibillmd.com\/blog\/wp-content\/uploads\/2026\/05\/Ultimate-Guide-to-CPT-Code-90960-1-150x150.webp",150,150,true],"medium":["https:\/\/medibillmd.com\/blog\/wp-content\/uploads\/2026\/05\/Ultimate-Guide-to-CPT-Code-90960-1-300x180.webp",300,180,true],"medium_large":["https:\/\/medibillmd.com\/blog\/wp-content\/uploads\/2026\/05\/Ultimate-Guide-to-CPT-Code-90960-1-768x461.webp",768,461,true],"large":["https:\/\/medibillmd.com\/blog\/wp-content\/uploads\/2026\/05\/Ultimate-Guide-to-CPT-Code-90960-1-1024x614.webp",1024,614,true],"1536x1536":["https:\/\/medibillmd.com\/blog\/wp-content\/uploads\/2026\/05\/Ultimate-Guide-to-CPT-Code-90960-1.webp",1200,720,false],"2048x2048":["https:\/\/medibillmd.com\/blog\/wp-content\/uploads\/2026\/05\/Ultimate-Guide-to-CPT-Code-90960-1.webp",1200,720,false]},"uagb_author_info":{"display_name":"faraz zahid","author_link":"https:\/\/medibillmd.com\/blog\/author\/faraz-zahid\/"},"uagb_comment_info":0,"uagb_excerpt":"Suppose a nephrology practice wraps up a month of dialysis management for a patient with end-stage renal disease (ESRD). It [&hellip;]","_links":{"self":[{"href":"https:\/\/medibillmd.com\/blog\/wp-json\/wp\/v2\/posts\/6468","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/medibillmd.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medibillmd.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/medibillmd.com\/blog\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/medibillmd.com\/blog\/wp-json\/wp\/v2\/comments?post=6468"}],"version-history":[{"count":1,"href":"https:\/\/medibillmd.com\/blog\/wp-json\/wp\/v2\/posts\/6468\/revisions"}],"predecessor-version":[{"id":6470,"href":"https:\/\/medibillmd.com\/blog\/wp-json\/wp\/v2\/posts\/6468\/revisions\/6470"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/medibillmd.com\/blog\/wp-json\/wp\/v2\/media\/6469"}],"wp:attachment":[{"href":"https:\/\/medibillmd.com\/blog\/wp-json\/wp\/v2\/media?parent=6468"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medibillmd.com\/blog\/wp-json\/wp\/v2\/categories?post=6468"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medibillmd.com\/blog\/wp-json\/wp\/v2\/tags?post=6468"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}