By Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer
Approximately 450,000 patients in the United States received dialysis treatments in 2014, according to the National Kidney Foundation. Dialysis is an artificial process used to clean the blood by removing excess water and waste products when the patient’s kidneys cannot do this. In addition to hospitals providing this service, independent centers and home health agencies help patients receive treatment.
Reporting diagnoses
Patients diagnosed with end-stage renal disease (ESRD) require dialysis treatments because their own kidneys no longer function properly, leaving behind waste products and excess fluid in the body. This condition is reported with ICD-10-CM code N18.6 (ESRD [chronic kidney disease requiring chronic dialysis]).
Underlying conditions, such as diabetes and high blood pressure can damage the patient’s renal system to this point, and they are considered the most common causes of ESRD in the United States. In these cases, reporting N18.6 will not be the first-listed diagnosis code. Instead first report:
- E10.22, Type 1 diabetes mellitus with diabetic chronic kidney disease
- E11.22, Type 2 diabetes mellitus with diabetic chronic kidney disease
- I12.0, hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
- I13.11, hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease or end stage renal disease
In addition, the patient’s status as a dialysis patient will need to be reported with Z99.2 (dependence on renal dialysis).
Commonly, the term dialysis serves a generic function for a category of renal replacement therapies. However, in reality, different types are performed.
Hemodialysis
With hemodialysis, a mechanical dialyzer extracts blood via an intravenous catheter, filters out waste products and excess fluids, and returns the “cleaned” blood back into the patient via an intra-arterial catheter. Typically, patients receive three sessions a week.
Prior to beginning ongoing hemodialysis treatments, the nephrologist will order the insertion of either an arteriovenous fistula or an arteriovenous graft. This is reported with CPT® code 36147 (introduction of needle and/or catheter, arteriovenous shunt created for dialysis [graft/fistula]; initial access including fluoroscopy, image documentation and report).
Hemodialysis procedures are reported with one of two CPT codes determined by the number of evaluations provided by the physician during the encounter:
- 90935, hemodialysis procedure with single evaluation by a physician or other qualified physician or other health care professional
- 90937, hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription
CPT also includes a code for hemodialysis services performed by a non-physician healthcare professional in the patient’s residence, including a private home, assisted living, group homes, nontraditional provider homes, custodial care facilities, or a school: 99512 (home visit for hemodialysis).
When hemodialysis is provided via an arteriovenous fistula, graft, or catheter, coders can use Category II codes to report this service:
- 4052F, hemodialysis via functioning arteriovenous fistula [ESRD]
- 4053F, hemodialysis via functioning arteriovenous graft [ESRD]
- 4054F, hemodialysis via catheter [ESRD]
Access flow studies may be provided to determine the effectiveness of the dialysis process. These may be reported with the following codes, depending on the method:
- 90940, hemodialysis access flow study to determine blood flow in grafts and arteriovenous fistulae by an indicator method
- 93990, transcranial Doppler study of the intracranial arteries, vasoreactivity study
Other renal therapies
Other types of dialysis may be provided to patients with renal failure. These include:
- Peritoneal dialysis: The catheter is connected to the abdominal cavity, using the peritoneal membrane to filter the blood
- Hemofiltration: A mechanical filtration circuit cleans the blood of waste products and excess fluid using a convection process
These procedures are reported with one of the following codes:
- 90945, dialysis procedure other than hemodialysis, with single evaluation by a physician or other qualified physician or other health care professional
- 90947, dialysis procedure other than hemodialysis, requiring repeated evaluation(s) by a physician or other qualified health care professional, with or without substantial revision of dialysis prescription
However, if these services are provided at the patient’s home by a non-physician professional, the following codes should be reported, depending on the length of the service:
- 99601, home infusion/specialty drug administration, per visit (up to two hours)
- Add-on code 99602, each additional hour
ESRD
When a patient is diagnosed with ESRD, dialysis services are reported on a monthly basis, rather than for each individual encounter, with a code from the 90951-90966. The correct code for reporting dialysis service is determined by:
- Patient’s age, grouped into ranges:
- Younger than 2
- 2–11 years old
- 12–19 years old
- 20 and older
- Location of where the services are performed, either an outpatient facility or through home dialysis
- Level of physician services determined by the number of face-to-face visits by a physician
If a facility does not provide a full month of services to a patient, for whatever reason, then you should use one code from the range 90967–90970, determined by the age of the patient, multiplied by each day of service.
E/M services that are not related to ESRD that cannot be performed during dialysis sessions can be reported separately.
Editor’s note: Safian, of Safian Communications Services in Orlando, Florida, is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee. Email her at ssafian@embarqmail.com.