Procedure-Specific Billing
Specialized Billing for Every Nephrology Service
Nephrology billing demands fluency in the ESRD capitation framework, precise CKD staging documentation, AV access procedure coding, and care management billing, all simultaneously. ProtoMed's certified team handles every service correctly across the full kidney care billing spectrum.
ESRD Monthly Capitation Billing
ESRD patients on dialysis are reimbursed under a monthly capitation model: a single monthly payment covers all dialysis-related services for the month. The correct G-code depends on whether the patient dialyzes at home or in-facility, and the per-visit threshold determines which code applies. E/M visits during the capitation period for dialysis-related conditions must not be billed separately. We manage ESRD capitation billing correctly, apply the right monthly codes, and protect your practice from compliance errors on the most high-volume billing in nephrology.
Dialysis-Related vs Unrelated Service Billing
The most important billing distinction in nephrology is whether an E/M service is related to or unrelated to the patient's ESRD. Services for hypertension management, anemia of CKD, and mineral metabolism are typically bundled into the ESRD capitation payment and cannot be billed separately. Services for acute conditions unrelated to kidney disease, infections, musculoskeletal complaints, cardiac events, are separately billable E/M visits. We correctly classify and bill every nephrology encounter within the ESRD framework, capturing all separately billable revenue while maintaining compliance.
AV Fistula & Vascular Access Billing
Arteriovenous fistula creation, graft placement, revision, and thrombectomy procedures are high-value claims that require precise code selection based on the specific procedure performed, the access site, and whether the procedure is a new creation or revision. Imaging guidance codes must be billed separately when used. We accurately code every AV access procedure, apply the correct laterality modifiers, and include imaging guidance add-on codes when applicable, capturing the full reimbursement value of every vascular access case.
CKD Staging & ICD-10 Coding
CKD staging specificity in ICD-10 affects multiple revenue streams simultaneously: HCC risk adjustment for Medicare Advantage patients, CCM billing eligibility, and payer-specific reimbursement rates. Documenting "CKD" without specifying the stage (N18.1 through N18.6) leaves risk-adjustment revenue on the table and may prevent CCM billing eligibility. We ensure every CKD encounter captures the documented GFR-based stage with full ICD-10 specificity, protecting both reimbursement and compliance across your entire CKD patient panel.
CCM & Care Management Billing
CKD patients, especially those in stages 3-5, frequently qualify for Chronic Care Management billing, representing $80-$140 per patient per month in recurring revenue. Monthly time tracking, care plan documentation, and patient consent are required. Transitional Care Management applies when CKD or ESRD patients are discharged from a facility. We manage the complete CCM and TCM billing cycle for your nephrology patient panel, capturing this recurring revenue stream without adding clinical burden to your team.
Kidney Transplant Follow-Up Billing
Post-transplant care involves high-complexity E/M visits, immunosuppression management, and close monitoring of transplant function, each billed under specific codes that differ from standard nephrology E/M visits. Transplant evaluation services for living donors require separate coding. We accurately code every transplant evaluation and follow-up encounter, ensuring the complexity of post-transplant management is captured at the correct E/M level with the documentation required to support each claim.
