How To Use CPT Code 90967

CPT 90967 describes the management of end-stage renal disease (ESRD) related services for dialysis for patients younger than 2 years of age. 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 90967?

CPT 90967 can be used to describe the management of daily outpatient ESRD related services for dialysis patients who are younger than 2 years old and receive dialysis services for less than one full month. This code is reported per day and is used in situations such as when a patient receives a partial month of dialysis, when a patient is traveling and receives services for less than a month, or when a patient has face-to-face visits without a complete assessment and experiences changes in their dialysis care during the month.

2. Official Description

The official description of CPT code 90967 is: ‘End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age.’

3. Procedure

1. The healthcare provider manages all the daily outpatient ESRD related services for a dialysis patient who is younger than 2 years old and receives dialysis services for less than one full month.
2. This code is reported per day, and the provider should document the specific services provided on each day.
3. Examples of situations where this code may be used include when a patient receives a partial month of dialysis, when a patient is traveling and receives services for less than a month, or when a patient has face-to-face visits without a complete assessment and experiences changes in their dialysis care during the month.

4. Qualifying circumstances

CPT 90967 is used for patients who are younger than 2 years old and have end-stage renal disease (ESRD). ESRD refers to the final stage of kidney failure where a patient is not able to live without dialysis or a transplant due to the complete or nearly complete irreversible loss of renal function. This code is specifically for patients who receive dialysis services for less than one full month.

5. When to use CPT code 90967

CPT code 90967 should be used when managing the daily outpatient ESRD related services for dialysis patients who are younger than 2 years old and receive dialysis services for less than one full month. It is important to report this code per day and ensure that the documentation supports the specific services provided on each day.

6. Documentation requirements

To support a claim for CPT 90967, the healthcare provider must document the following information:

• Patient’s age and diagnosis of end-stage renal disease (ESRD)
• Start and end dates of the dialysis services provided
• Specific services provided on each day, including any changes in the dialysis care
• Any face-to-face visits without a complete assessment and the reason for the changes in dialysis care
• Signature of the healthcare provider managing the ESRD related services

7. Billing guidelines

When billing for CPT 90967, ensure that the patient is younger than 2 years old and receiving dialysis services for less than one full month. Report this code per day, and document the specific services provided on each day. It is important to follow Medicare guidelines for payment of ESRD-related services under the Monthly Capitation Payment. Consider the calendar month when determining the start and end dates for reporting this code.

8. Historical information

CPT 90967 was added to the Current Procedural Terminology system on January 1, 2009. There have been no updates to the code since its addition.

9. Examples

1. A 1-year-old patient receives dialysis services for 15 days in a month due to a temporary change in their dialysis care.
2. A 6-month-old patient receives dialysis services for 10 days in a month while traveling away from home.
3. A 2-year-old patient receives dialysis services for 25 days in a month due to changes in their dialysis care after a face-to-face visit without a complete assessment.
4. An 8-month-old patient receives dialysis services for 20 days in a month as they transition to a new healthcare provider.
5. A 1-year-old patient receives dialysis services for 5 days in a month as they receive a partial month of dialysis due to hospitalization.
6. A 10-month-old patient receives dialysis services for 30 days in a month as they require daily dialysis for their ESRD.
7. A 1-year-old patient receives dialysis services for 12 days in a month as they receive a partial month of dialysis due to a transplant.
8. A 9-month-old patient receives dialysis services for 18 days in a month as they receive a partial month of dialysis due to death.
9. A 6-month-old patient receives dialysis services for 8 days in a month as they receive a partial month of dialysis before permanently changing their healthcare provider.
10. A 1-year-old patient receives dialysis services for 22 days in a month as they receive a partial month of dialysis due to changes in their dialysis care after a face-to-face visit without a complete assessment.