How To Use CPT Code 90962

CPT 90962 describes the monthly management services provided to patients aged 20 and older with end-stage renal disease (ESRD). This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 90962?

CPT 90962 can be used to describe the monthly management services provided to patients aged 20 and older with end-stage renal disease (ESRD). This code is used when a physician or other qualified healthcare professional has a face-to-face visit with the patient once a month to oversee and manage their ESRD-related care.

2. Official Description

The official description of CPT code 90962 is: ‘End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 1 face-to-face visit by a physician or other qualified health care professional per month.’

3. Procedure

1. The healthcare professional manages all outpatient ESRD-related services for a one-month period for patients aged 20 and older.
2. During this period, the healthcare professional has a face-to-face visit with the patient once to provide comprehensive care.
3. The bundled services included in this code encompass scheduled and episodic examinations, establishment and changes to the patient’s dialysis schedule and prescription, oversight of each dialysis visit, review of laboratory tests, medication and supplement needs, short and long-term care plans, telephone and electronic communications, care coordination, and regular counseling and support for the patient and/or caregivers.

4. Qualifying circumstances

Patients eligible to receive CPT 90962 services are those aged 20 and older with end-stage renal disease (ESRD). ESRD refers to the final stage of kidney failure where a patient cannot live without dialysis or a transplant due to the complete or nearly complete irreversible loss of renal function. The healthcare professional providing the service must have a face-to-face visit with the patient once a month to manage their ESRD-related care.

5. When to use CPT code 90962

CPT code 90962 should be used when a physician or other qualified healthcare professional has a face-to-face visit with a patient aged 20 and older with end-stage renal disease (ESRD) once a month to manage their ESRD-related care. This code should be reported for each month in which the visit occurs.

6. Documentation requirements

To support a claim for CPT 90962, the healthcare professional must document the following information:

• Patient’s age and diagnosis of end-stage renal disease (ESRD)
• Date of the face-to-face visit
• Details of the services provided during the visit, including examinations, dialysis schedule and prescription management, laboratory test review, medication and supplement needs, care plans, and counseling and support
• Any telephone or electronic communications related to the patient’s care
• Care coordination activities
• Signature of the physician or other qualified healthcare professional providing the service

7. Billing guidelines

When billing for CPT 90962, ensure that the visit is face-to-face and conducted by a physician or other qualified healthcare professional. This code should not be reported for dialysis treatment, which has separate codes (90935-90937). It is important to note that Medicare considers a month as a calendar month for payment of ESRD-related services under the Monthly Capitation Payment. Additionally, be aware of any specific guidelines or requirements from third-party payers when reporting this code.

8. Historical information

CPT 90962 was added to the Current Procedural Terminology system on January 1, 2009. On January 1, 2013, the code description was revised to include the term ‘other qualified health care professional’ in addition to physicians.

9. Examples

1. A physician has a face-to-face visit with a 25-year-old patient with end-stage renal disease (ESRD) to oversee their monthly care and manage their dialysis schedule and prescription.
2. A nephrologist conducts a comprehensive examination and review of laboratory tests during a face-to-face visit with a 60-year-old patient with end-stage renal disease (ESRD).
3. A qualified healthcare professional provides counseling and support to a 70-year-old patient with end-stage renal disease (ESRD) and their caregiver during a face-to-face visit.
4. A physician adjusts the medication and supplement needs of a 45-year-old patient with end-stage renal disease (ESRD) during a face-to-face visit.
5. A healthcare professional coordinates the care and provides regular counseling to a 55-year-old patient with end-stage renal disease (ESRD) during a face-to-face visit.
6. A nephrologist establishes a long-term care plan and discusses dietary changes with a 50-year-old patient with end-stage renal disease (ESRD) during a face-to-face visit.
7. A physician reviews the patient’s dialysis schedule and prescription and oversees each dialysis visit during a face-to-face visit with a 65-year-old patient with end-stage renal disease (ESRD).
8. A qualified healthcare professional provides telephone and electronic communications regarding the care of a 75-year-old patient with end-stage renal disease (ESRD).