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Nephrology Billing Services
Most of a nephrology practice's dialysis revenue arrives once a month, through ESRD monthly capitation codes (90951–90970) set by the patient's age, the number of face-to-face visits, and whether dialysis is in-center or at home. One missed visit or a hospitalization mid-month changes the code. Qualigenix bills MCP from your visit logs, handles partial months and home dialysis, and checks ESRD coordination of benefits before each claim.
What Nephrology Billing Demands
Nephrology billing demands correct ESRD monthly capitation coding by age and visit count, separate rules for home dialysis and partial months, Medicare Secondary Payer checks for ESRD patients with group health coverage, and E/M and care-management billing for CKD and transplant patients. Qualigenix's coders bill nephrology practices and dialysis-affiliated groups with a 98.2% first-pass clean claim rate on first submission. Start with a free billing audit at 786-259-0231.
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MCP Coding by Age and Visits
In-center MCP codes are split into four age groups (under 2, 2–11, 12–19, and 20 and older) and three visit tiers (four or more visits, two to three, and one). A patient seen four times but billed at the two-to-three tier loses the difference every month.
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Drug and Transplant Prior Auth
Commercial and Medicare Advantage plans often require approval for specialty renal drugs, biologics for glomerular disease, advanced imaging, and transplant evaluations. Approvals expire, and a lapsed one stops payment.
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Partial-Month and Home Dialysis
Home dialysis is billed with full-month codes (90963–90966) or, for partial months, per-day codes (90967–90970). Per-day codes also apply in other partial-month situations Medicare defines, such as a transplant, a change of managing physician, or the patient's death. Inpatient dialysis is billed separately with 90935, 90937, 90945, or 90947.
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Home Dialysis Telehealth
Medicare allows monthly ESRD visits for home dialysis patients by telehealth, but the patient needs a face-to-face visit at least monthly for the first three months and at least once every three consecutive months after that. CKD follow-ups by telehealth follow each payer's general telehealth rules.
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The 30-Month Coordination Period
When an ESRD patient has employer group health coverage, that plan pays first during a 30-month coordination period and Medicare pays second. Claims sent to Medicare first during that window are denied or recouped.
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MCP Visit Documentation
Each MCP claim needs a dated record of every visit counted toward the tier. For in-center patients, Medicare requires at least one visit each month to be face to face, with an exam of the vascular access site.
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Recurring Denials
The recurring nephrology denials come from E/M visits for ESRD-related care billed in the same month as MCP, two physicians billing MCP for the same patient and month, and care-management codes that overlap with MCP.
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ESRD and Kidney Care Model Rules
Medicare ESRD billing follows its own chapter of the Claims Processing Manual, and practices taking part in a CMS kidney care model, such as Kidney Care Choices, carry additional attribution and reporting rules.
How Qualigenix Fixes Nephrology Billing, Month by Month
Qualigenix fixes nephrology billing on a monthly cycle: count the visits, set the MCP code, adjust for partial months, and check the payer order before the claim goes out.
Visit-Based MCP Coding
Coders count documented visits for each patient each month and assign the MCP code for the patient's age group and visit tier.
Renal Auth Management
We track approvals for specialty renal drugs, biologics, imaging, and transplant evaluations and request renewals before they expire.
Partial-Month Adjustments
We flag hospitalizations, transplants, physician changes, and deaths during the month and switch to per-day codes where Medicare's rules require them.
Home Dialysis Telehealth Tracking
We track each home dialysis patient's in-person visit schedule so telehealth months stay within Medicare's face-to-face requirement.
ESRD Payer-Order Checks
We check every ESRD patient for group health coverage and track the 30-month coordination period so each claim goes to the correct primary payer.
Visit Documentation Review
We confirm each counted visit is dated and documented, and that in-center patients have a monthly in-person vascular access exam on record.
Denial Appeals
Our denial team overturns 79% of the denials it works, with an average appeal turnaround under 9 days. Overlap appeals show why the E/M or care-management service was separate from MCP care.
ESRD Compliance Monitoring
We audit MCP, home dialysis, and care-management claims each month against Medicare ESRD billing rules.
CASE STUDY 01
How a 3-provider podiatry group cleared $214K in aged A/R
THE SITUATION
A 3-provider podiatry group with roughly 60% Medicare payer mix carried $412,000 in A/R, 38% of it past 120 days. Routine foot care claims (11720, 11721, 11055–11057) had stalled on inconsistent Q7/Q8/Q9 modifiers and class-finding documentation, so payers held or partially paid and nobody worked the remainder. Medicare crossover to secondaries was not being posted, and small patient balances were written off.
WHAT QUALIGENIX DID
We ran a full A/R aging segmentation, worked claims by payer and denial reason rather than by date, rebilled the stalled routine-care claims with corrected modifiers, and reactivated secondary and crossover billing.
Key Outcomes & Turnaround
38% to 14%A/R past 120 days
$214,000recovered from aged A/R
90 daysto turn it around
~60%Medicare payer mix
Audited Practice Results
How a solo podiatrist lifted first-pass acceptance to 96%
THE SITUATION
A solo podiatrist coding 320 encounters a month was stuck at 82% first-pass acceptance. Routine foot care went out without the systemic-condition diagnosis pairing and class findings Medicare requires, so it read as non-covered. Wound debridement was coded to the wrong depth (11042 for skin and subcutaneous where the note supported 11043 for muscle and fascia). Same-day E/M with a procedure went out without modifier 25 and got bundled.
WHAT QUALIGENIX DID
We rebuilt the coding workflow: diagnosis-to-CPT pairing rules for at-risk foot care, correct Q-modifier logic, depth-based debridement coding tied to the operative note, and disciplined use of modifiers 25 and 59/XS.
Key Outcomes & Turnaround
82% to 96%first-pass acceptance
+11%per-encounter reimbursement
60 daysto turn it around
320/moencounters coded
Audited Practice Results
How a 2-location podiatry practice cut its denial rate by two-thirds
THE SITUATION
A 2-location podiatry practice sat at a 19% denial rate, mostly Medicare routine-foot-care and nail-debridement rejections. The denials clustered in three buckets: medical-necessity rejections on routine foot care (missing qualifying diagnosis and class findings), frequency-edit denials on nail debridement billed inside the 60-day window, and missing Q modifiers that flagged services as non-covered.
WHAT QUALIGENIX DID
We built a front-end denial-prevention layer, checking eligibility and coverage against payer LCDs before claims went out, plus a structured appeal workflow with documentation templates mapped to each denial reason.
Key Outcomes & Turnaround
19% to 6%denial rate
$68,000recovered on appealed claims
4 monthsto turn it around
2 locationspractice size
Audited Practice Results
Nephrology Coding From CKD Through Dialysis and Transplant
Qualigenix codes nephrology by stage of care, because CKD, dialysis, vascular access, and transplant each use different code families.
CKD Visits and Education
Codes: 99202–99215, G0420, G0421. Office visits for CKD patients, and individual or group kidney disease education for Medicare patients with stage 4 CKD.
Nephrology Groups We Support
Qualigenix supports nephrology practices, dialysis-affiliated nephrology groups, home dialysis programs, transplant nephrology programs, interventional nephrology and vascular access centers, hospital-based nephrology services, and multi-specialty renal networks.
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Variance Threshold
Why Nephrology Practices Choose Qualigenix
Our nephrology coders work with MCP visit rules, home dialysis billing, and ESRD coordination of benefits on every claim. They review Medicare ESRD and MPFS changes each year, so a rule change is applied before it reaches your claims.
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IMPROPER PAYMENT RATE
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QUESTIONS BUYERS ASK
Qualigenix prices nephrology billing after reviewing your dialysis census, CKD volume, payer mix, and the services you want to hand over. Most nephrology groups start with a free billing audit so the quote reflects real numbers.
Coders count every documented face-to-face visit for each patient each month and assign the code for the patient's age group and visit tier. A free audit shows how often your current claims are billed below the documented tier.
We check every ESRD patient for employer group health coverage and bill that plan first during the 30-month coordination period, with Medicare as secondary.
Yes. We work outstanding nephrology claims by denial reason and timely-filing limit, starting with the highest-value accounts. A free AR review shows how much is still recoverable.
For in-center patients, we bill the MCP code for the visits documented during the month. For home dialysis patients and other partial-month situations Medicare defines, we bill per-day codes 90967–90970.
Yes. Medicare allows monthly ESRD visits for home dialysis patients by telehealth, as long as the patient has a face-to-face visit monthly for the first three months and at least once every three consecutive months after that.
Qualigenix works across 133 EMR/EHR platforms. We confirm access to Acumen, Falcon, or your current EHR during the free billing audit.
Qualigenix's average onboarding time is 6 days. That covers system access, payer enrollment checks, and coder assignment before we take over claim submission.