Local Coverage Article Billing and Coding

Billing and Coding: Frequency of Hemodialysis


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Contractor Information

Article Information

General Information

Article ID
Article Title
Billing and Coding: Frequency of Hemodialysis
Article Type
Billing and Coding
Original Effective Date
Revision Effective Date
Revision Ending Date
Retirement Date
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CMS National Coverage Policy


Article Guidance

Article Text

Refer to the National Government Services Local Coverage Determination (LCD) L37475, Frequency of Hemodialysis, for reasonable and necessary requirements and frequency limitations.

The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

This article outlines how to line item bill dialysis sessions for End Stage Renal Disease (ESRD) patients. This does not address line item billing for sessions associated with training or other modalities such as peritoneal dialysis. This article does not change any other billing requirements for dialysis claims. Note: This article uses the terms dialysis ‘session’ and ‘treatment’ interchangeably.

CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 8 requires line item billing for all ESRD claims with dates of service (DOS) on or after April 1, 2007. Each dialysis session performed should be reported on a separate line.

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 11 discusses that ESRD facilities furnishing dialysis treatments in facility or in the beneficiary’s home are paid for up to 3 treatments per week. Payment for additional treatments, defined as any treatments in excess of 3 treatments per week, may be considered in addition to the ESRD PPS per treatment payment amount paid for up to 3 treatments per week.

For monthly claims submitted with Bill Type 72X and Revenue Codes 0821 and 0881, three approaches of billing per line are available. Based on the Patient’s Plan of Care (POC), or other available medical documents, the following scheme should be followed when billing sessions. Note: Dialysis sessions in the patient’s POC that are not furnished should not be billed.

  1. For dialysis sessions that have been furnished 3 times (3X) per week, each line should be 90999 without any modifiers appended. That is, when the hemodialysis-prescription is 3 times (3X) per week and each session is furnished, all of these sessions be billed as 90999 (no modifier appended) and they will be paid as routine conventional dialysis up to 13/14 per month.

  2. For each dialysis sessions furnished in addition to the 3 sessions per week that do not include medical documentation supporting a reasonable and necessary determination for payment, each line for these sessions should be billed as 90999 CG. Examples of when this could occur include short, more frequent treatments furnished for the convenience of the patient or staff, etc. Additional sessions need to be billed as 90999 CG when medical documentation has not been submitted to support the extra sessions as reasonable and necessary. The CG modifier indicates that the facility attests the additional treatment is not reasonable and necessary and should not receive additional payment. Each line billed as 90999 CG will be denied. However, the use of the modifier is used for data analysis. Please refer to CR 9989, Implementation of Modifier CG for Type of Bill 72X, dated May 12, 2017.

  3. For each dialysis session furnished in addition to 3 sessions per week that includes medical documentation supporting a reasonable and necessary determination for payment, each line for these services should be billed as 90999 KX. These include medical conditions for acute and occasionally chronic conditions that have supporting documentation that the extra sessions are reasonable and necessary (e.g. through documents from recent hospital care, office visits, dialysis progress notes or MCP visits). These sessions must be reasonable and necessary for additional payment based on clinical conditions. On these claims, the 90999 lines without a modifier will be paid as 3X per week and those lines with 90999 KX will be considered for additional payments. Omission of the KX modifier will result in no additional payment for the line item. For diagnoses not listed in this article but felt to be reasonable and necessary, the KX modifier should be appended as well. A denial will occur on these lines, but the redetermination process (an appeal) will be available to submit supportive documentation for review.

The expectation is that these three scenarios will be seen on monthly claims, i.e., claims with 90999 lines only, or those with lines of 90999 mixed with 90999 CG or KX modifier appended. Ongoing data analysis may trigger provider specific requests for documentation should unusual patterns occur, i.e., claims with only lines of 90999 KX submitted.

Please note that the POC and other supporting medical documentation to justify any of the line item sessions will be most important and may be requested.

Please see L37475 for instructions when clinical conditions outside those listed in the available diagnoses should occur.

Please see L37475 for Documentation Requirements and Utilization Guidelines.



Coding Information


Group 1

(1 Code)
Group 1 Paragraph

Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes

CPT/HCPCS Modifiers


ICD-10-CM Codes that Support Medical Necessity

Group 1

(56 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Medicare is establishing the following limited coverage for CPT/HCPCS code: 90999 (when reported to represent an extra dialysis session)

Group 1 Codes
E83.30 Disorder of phosphorus metabolism, unspecified
E83.39 Other disorders of phosphorus metabolism
E87.20 Acidosis, unspecified
E87.21 Acute metabolic acidosis
E87.22 Chronic metabolic acidosis
E87.29 Other acidosis
E87.5 Hyperkalemia
E87.70 Fluid overload, unspecified
E87.71 Transfusion associated circulatory overload
E87.79 Other fluid overload
I30.0 Acute nonspecific idiopathic pericarditis
I30.1 Infective pericarditis
I30.8 Other forms of acute pericarditis
I30.9 Acute pericarditis, unspecified
I32 Pericarditis in diseases classified elsewhere
I50.1 Left ventricular failure, unspecified
I50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
I50.30 Unspecified diastolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33 Acute on chronic diastolic (congestive) heart failure
I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.810 Right heart failure, unspecified
I50.811 Acute right heart failure
I50.812 Chronic right heart failure
I50.813 Acute on chronic right heart failure
I50.814 Right heart failure due to left heart failure
I50.82 Biventricular heart failure
I50.83 High output heart failure
I50.84 End stage heart failure
I50.89 Other heart failure
I50.9 Heart failure, unspecified
I77.0 Arteriovenous fistula, acquired
I95.3 Hypotension of hemodialysis
J81.0 Acute pulmonary edema
M32.12 Pericarditis in systemic lupus erythematosus
N25.81 Secondary hyperparathyroidism of renal origin
O09.211 Supervision of pregnancy with history of pre-term labor, first trimester
O09.212 Supervision of pregnancy with history of pre-term labor, second trimester
O09.213 Supervision of pregnancy with history of pre-term labor, third trimester
O09.219 Supervision of pregnancy with history of pre-term labor, unspecified trimester
O09.891 Supervision of other high risk pregnancies, first trimester
O09.892 Supervision of other high risk pregnancies, second trimester
O09.893 Supervision of other high risk pregnancies, third trimester
O09.899 Supervision of other high risk pregnancies, unspecified trimester
R60.1 Generalized edema
R63.5 Abnormal weight gain
T82.898A Other specified complication of vascular prosthetic devices, implants and grafts, initial encounter
T82.898D Other specified complication of vascular prosthetic devices, implants and grafts, subsequent encounter
T82.898S Other specified complication of vascular prosthetic devices, implants and grafts, sequela

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10 Codes that are Covered” section of this article.

Group 1 Codes
XX000 Not Applicable

ICD-10-PCS Codes


Additional ICD-10 Information


Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

072x Clinic - Hospital Based or Independent Renal Dialysis Center

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.


Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Medicare Claims Processing Manual, for further guidance.

0821 Hemodialysis - Outpatient or Home - Hemodialysis Composite or Other Rate
0881 Miscellaneous Dialysis - Ultrafiltration

Other Coding Information


Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/01/2022 R3

Due to the annual ICD-10 updates for 2023, ICD-10 code E87.2 is being deleted and is replaced by codes E87.20, E87.21, E87.22, E87.29

10/01/2019 R2

Article revised and published on 10/01/2019 in response to an inquiry to add clarification to the approaches for billing hemodialysis sessions. Additionally, due to system changes in response to CMS Change Request 10901, this article has undergone some reorganization in the coding section and the following new fields have been added: CPT/HCPCS Modifier, Additional ICD-10 Information, and Other Coding Information.

07/01/2019 R1

Article revised and published on 07/04/2019 effective for dates of service on and after 07/01/2019. Consistent with CMS Change Request (CR) 10901, the CPT and ICD-10 codes have been removed from the related LCD and added to the article. In response to an inquiry, language in Article Text item #1 has been modified for clarification regarding the hemodialysis prescription.

Associated Documents

Related Local Coverage Documents
L37475 - Frequency of Hemodialysis
Related National Coverage Documents
Statutory Requirements URLs
Rules and Regulations URLs
CMS Manual Explanations URLs
Other URLs
Public Versions
Updated On Effective Dates Status
09/21/2022 10/01/2022 - N/A Currently in Effect You are here
09/20/2019 10/01/2019 - 09/30/2022 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.