- 1178 Broadway, NY 10001
- 30 N Gould St Ste N, Sheridan, WY, 82801
- +1-(929)-621-6059
- info@medstates.com
- accounts@medstates.com
- www.medstates.com
© 2025, MedStates. All Rights Reserved.
Nephrology billing services play a crucial role in keeping kidney care practices financially healthy while ensuring compliance with ever-changing payer rules. From chronic kidney disease (CKD) to end-stage renal disease (ESRD) and dialysis management, nephrology involves a high volume of recurring visits, bundled payments, and intricate coding. That is where specialized nephrology billing support becomes indispensable. At MedStates, we provide nationwide nephrology billing services for nephrologists in every U.S. State. Whether you run a dialysis center, hospital-based nephrology group, or private kidney clinic, our expert nephrology billing services assist you comply with payer requirements and compliance with industry standards.
Nephrology billing is not just about submitting claims, it is about understanding how kidney care intersects with multiple reimbursement models, chronic disease management programs, and federal payer policies. Unlike routine physician billing, nephrology encounters involve recurring visits, dialysis treatments, and shared patient care, which all require precise documentation and coding. Therefore, each nephrology claim must accurately reflect the service type, dialysis frequency, and patient’s CKD or ESRD stage. Or else, even minor documentation gaps can trigger denials or payer audits when managing overlapping coverages between Medicare, Medicaid, and private insurers.
Our nephrology billing services are designed manages complete cycle of kidney care reimbursements from insurance verification to denial resolution. MedStates rank amongst the top 5 nephrology billing companies with hands on experience of nephrology coding, dialysis billing, and ESRD claim management.
We assist nephrology practices in enrolling with Medicare, Medicaid, and commercial insurers. Our credentialing experts manage all paperwork, track application status for uninterrupted reimbursements
Before each dialysis session or a nephrology patient visit, our team verifies insurance status, coverage limitations, and coordination of benefits. This proactive verification eliminates eligibility-related denials
Nephrology procedures, especially renal imaging, dialysis initiation, and injectable medications, often require prior authorization. We ensure the provided services are preapproved and reimbursed without delays.
Our certified coders specialize in mapping nephrology documentation to precise codes that capture CKD stages, ESRD treatments, and dialysis sessions adhering with CMS and AMA coding guidelines
Once claims are scrubbed and coded, our team submits them electronically to all payers on prescribed format, for real-time tracking and automated alerts to achieve 97% claim acceptance rate
For 3% claim denials, our nephrology billing specialists analyze denial trends to identify the root cause followed up with appeals and resubmission — turning denials into recovered revenue
Every payment and adjustment is accurately posted into your billing software, creating a clear audit trail. We also provide monthly reports to track key performance indicators
Accurate coding is the foundation of successful nephrology billing. Each encounter — whether it’s a dialysis session, CKD follow-up, or renal procedure — requires precise CPT, ICD-10, and HCPCS code selection. Our best nephrology billing services ensure every claim accurately represents the medical necessity and scope of care for understanding of the payer, so to ensure minimized denials and optimized reimbursement.
| CPT Code | Description / Use Case |
|---|---|
| 90935 | Hemodialysis procedure requiring a physician’s evaluation. |
| 90937 | Hemodialysis with repeated evaluation or prolonged session. |
| 90945 | Peritoneal dialysis—single exchange procedure. |
| 90947 | Peritoneal dialysis—repeated or prolonged procedure. |
| 99214 | Established patient E/M visit for ongoing CKD or ESRD management. |
| G0317–G0323 | Chronic care management codes for complex CKD coordination under Medicare. |
| ICD-10 Code | Description / Clinical Condition |
|---|---|
| N18.1–N18.6 | Chronic kidney disease (CKD), stages 1–5 and ESRD. |
| I12.9 | Hypertensive chronic kidney disease without heart failure. |
| E11.22 | Type 2 diabetes mellitus with diabetic CKD (nephropathy). |
| N25.81 | Secondary hyperparathyroidism due to renal disease. |
| Z99.2 | Dependence on renal dialysis. |
| HCPCS Code | Description / Application |
|---|---|
| J1756 | Injection, iron sucrose, 1 mg — for anemia in CKD/ESRD patients. |
| J0885 | Injection, epoetin alfa, 1000 units — for erythropoietin therapy. |
| A4657 | Dialysis tubing, per set — used during hemodialysis sessions. |
| A4913 | Dialysis solution or disposable supplies. |
| J2997 | Injection, alteplase (tPA) — used to declot dialysis catheters. |
Modifiers play a crucial role in nephrology billing services, helping ensure accurate reimbursement and preventing claim denials for complex renal care scenarios. Modifier 25 is commonly used when a nephrologist provides a separately identifiable E/M service on the same day as a dialysis procedure. Modifier 59 distinguishes distinct procedural services that are medically necessary but typically not billed together. Modifier 76 is applied when the same nephrologist repeats a diagnostic test or service within a single day, while Modifier 91 is used for repeated lab tests essential for dialysis management and ongoing CKD monitoring. Additionally, Modifier 26 identifies the professional component when a nephrologist interprets diagnostic tests and the facility bills for the technical portion. Using these modifiers correctly in nephrology billing ensures compliance, reduces denials, and maximizes revenue integrity.
👉 For an in-depth understanding of modifier usage, refer to our detailed Modifiers in Medical Billing guide.
In nephrology billing, POS 11 is used for nephrology consultations in private practices and outpatient offices (refer to our Place of Service 11 in Medical Billing guide for complete details). POS 21 applies to inpatient hospital settings for nephrology consults or dialysis during hospital stays, while POS 22 is designated for outpatient hospital visits. For dialysis sessions performed in dedicated facilities, POS 65 is used to represent End-Stage Renal Disease (ESRD) treatment centers.
👉 For an in-depth understanding of POS usage, refer to Place of Service in Medical Billing guide.
Nephrology billing requirements differ widely across states. In California, Medi-Cal mandates duration-based modifiers for dialysis, while Texas payers often require preauthorization for CKD follow-ups. Whereas, Florida and New York enforce strict documentation and modifier rules for ESRD treatments, and Illinois denies claims lacking proper CKD-stage coding. States like Ohio, Georgia, and North Carolina have varying Medicaid and POS-based policies affecting dialysis reimbursement, while Michigan requires separate billing for hemodialysis and peritoneal dialysis. Understanding these state-specific nephrology billing variations is key to avoiding denials and maximizing revenue.
Each of these state-level variations reflects how complex nephrology billing truly is. When payers, counties, or Medicaid plans for kidney care require different documentation or modifier rules, even the smallest inconsistency can result in denials, audits, or underpayments.
Every insurance payer has its own nephrology billing policies, modifier rules, and documentation protocols. Since nephrology services — particularly dialysis, CKD management, and transplant-related care — are high-cost and frequently audited, therefore, understanding payer-specific variations is crucial for accurate reimbursement. At MedStates, our nephrology billing specialists work closely with all major public and private insurers to stay compliant with their ever-evolving requirements. Below is a comparative summary of the key payer differences that affect nephrology billing across the U.S.
| Insurance Payer | Key Billing Requirement | Common Nephrology Codes Affected | Documentation / Modifier Requirement |
|---|---|---|---|
| Medicare | Strict ESRD monthly capitation payment (MCP) structure; bundled reimbursement for dialysis-related care. | CPT 90960–90962 | Must include complete date range of services and POS 11 or 65 as applicable. |
| Medicaid (State-specific) | Varies by state — some Medicaid plans require prior authorization for CKD and ESRD visits. | CPT 99214, 90935, 90937 | State-specific modifiers like U1, U2, or GT required in telehealth claims. |
| Blue Cross Blue Shield (BCBS) | Different plans follow regional guidelines (e.g., BCBS TX vs. BCBS CA). | CPT 90999, 99213, 90945 | Requires claim-level authorization codes; missing codes cause automatic denials. |
| Aetna | Prefers electronic claim submissions through Availity; audits high-frequency dialysis billing. | CPT 90935, 99214 | Requires CKD stage documentation; nephrologist NPI must match treating provider. |
| Cigna | Requests documentation for every ESRD claim beyond 12 months. | CPT 90960, 90961 | Add modifier 25 for same-day consults and 59 for bundled service separation. |
| UnitedHealthcare (UHC) | Monitors frequency of CPT 90935/90937 within the same billing period. | CPT 90935, 90937 | Use correct ICD-10 N18.x stage code; incorrect linkage leads to denials. |
| Humana | Implements payer-specific dialysis documentation requirements; frequent audits in southern states. | CPT 90999, 99215 | Requires supporting clinical notes for every recurring dialysis session. |
| Tricare | Requires preauthorization for ESRD and transplant-related visits. | CPT 90960, 99214 | Military-specific place-of-service rules; POS 11 preferred for in-office care. |
| Kaiser Permanente | Bundled billing policy for nephrology consults within same facility. | CPT 99213, 90935 | Requires electronic claim attachments and proof of medical necessity. |
| Commercial Payers (regional) | Regional plans (e.g., Independence, Highmark) have custom CKD care pathways. | CPT 90935–90937, 99214 | Attach dialysis duration, stage, and care plan for each monthly claim. |
Our nephrology billing team ensures that every claim meets the exact specifications of the respective payer — from prior authorizations to modifier validation. We integrate payer updates, local coverage determinations (LCDs), and NCCI edits into your billing workflow to eliminate denials and accelerate cash flow.
At MedStates, we bring together the precision of certified medical coders, the insight of nephrology specialists, and the compliance expertise of billing professionals who understand every payer and state rule. Our goal is simple — to help nephrologists maximize reimbursements, minimize denials, and gain financial transparency in their practice. Here is what makes our nephrology billing company stands out:
Our billing professionals are trained specifically in nephrology and renal care billing. From dialysis CPTs (90935–90999) to ESRD monthly claims, we handle every scenario with accuracy and compliance.
Whether you operate a dialysis center, serve as a hospital-based nephrologist, or manage a private nephrology clinic, our team tailors workflows to match your facility’s setup, payer mix, and EHR system. See this to find an EHR for your nephrology practice
With rigorous internal audits and real-time claim scrubbing, our nephrology billing process ensures that nearly every claim submitted is accepted on the first attempt — cutting rework and AR delays. Curious to know what clean claim is? Read this guide on clean claims in medical billing
We integrate directly with leading EHRs — including, but not limited to, Epic, eClinicalWorks, Athenahealth, and Kareo — to streamline documentation, charge capture, and claim creation without disrupting your existing workflows.
Our analytics-driven approach focuses on reducing Accounts Receivable (AR) days, improving collection ratios, and identifying underpayment trends — ensuring your nephrology practice reaches its true earning potential.
💡 We combine technology, training, and payer-specific expertise to bring clarity and profitability to your nephrology RCM.
Nephrology billing demands precision, payer-specific insight, and constant adaptation to regulatory changes. At MedStates, we bring all three together — helping nephrologists and renal care providers achieve error-free billing, faster reimbursements, and full revenue transparency.
Whether you are an independent nephrologist, a group practice, or a dialysis facility, when you search for nepehrology billing services near me, you see how our kidney care billing solutions fit your practice. From credentialing and preauthorization to denial prevention and appeals, we handle everything so you can focus on kidney care patients. When you outsource your nephrology billing services to MedStates, you get:
“MedStates is more than a billing partner — we become an extension of our nephrology practice.”
📞 Contact us today to schedule a free consultation and discover how best nephrology billing services improve your practice health.
Get Free Practice Audit
Gain expert insights into your Practice’s current performance and the ways to improve that further.
Book your slot now!
This will close in 50 seconds