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Dialysis 90970

  1. Default Dialysis 90970
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    I'm auditing a provider whom sees/manages dialysis for a patient at a free standing dialysis clinic. The physician is billing 90970 daily because there was no comprehensive visit done for the month and it's less than a full month however, there are charges for days that the patient isn't in the clinic? For example, I was looking at one date of service where he billed a 90970 and Medicare paid however when I requested to review the note for this dos I was told there was no note because the patient wasn't seen in the clinic that day. When I reviewed the billing and compared to the notes I had, there were several dates billed with this code in April, but I only had 3 notes. What am I missing here? My interpretation of 90970 is that the provider would need to see the patient face to face and document the days he/she's seen the patient in order to bill??

    So my bottom line question is, can 90970 be billed daily by the provider whom is managing the dialysis plan for the patient for less than a full month, regardless of seeing the patient face to face?

    I haven't audited nephrology before and I'm not familiar with dialysis so any information or insight would be greatly appreciated!

    Thank you,
    Melanie S

  2. #2
    Its per day even if the physician is not there. I know its confusing based on the number if units, where it looks like over billing. If you consider the RVU it makes more sense.

    90970 daily = RVU 0.22 which is ~1/30 of the RVU of median 2-3 visit monthly code 90961

    From the CPT guidelines

    Codes 90967-90970 are reported to distinguish age-specific services for end-stage renal disease (ESRD) services for less than a full month of service, per day, for services provided under the following circumstances: transient patients, partial month where there was one or more face-to-face visits without the complete assessment, the patient was hospitalized before a complete assessment was furnished, dialysis was stopped due to recovery or death, or the patient received a kidney transplant. For reporting purposes, each month is considered 30 days.
    Last edited by CodingKing; 09-07-2018 at 04:10 PM.
    CRC (2018), CPC-P-A (2016), COC-A (2016), CPC-A (2015), PAHM (2010)
    Contract/Fee Specialist - Remote

    20 years health insurance experience: Audit, Claims, Customer Service, Payment Policy, Provider Relations, and Reimbursement

  3. #3
    What is needed for documentation for the complete assessment that is being done monthly?
    Steph Mescher, CPC

  4. Default Wonderful-thank you!
    Medical Billing
    I appreciate the response and the information, makes sense to me.
    Step- I've been trying to find out the documentation requirements as well and haven't come across anything definitive. If I find anything I will add to this thread.

    Thank you again and have a wonderful weekend!
    Melanie S

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