Summary & Overview
CPT 90935: Hemodialysis Procedure with Single Physician Evaluation
CPT code 90935 is a nationally recognized billing code for hemodialysis procedures involving a single physician evaluation. This code is essential for documenting and reimbursing acute hemodialysis services provided in hospital inpatient or outpatient dialysis settings. The code is widely used by nephrology and internal medicine physicians, as well as nurse practitioners, to capture the clinical work associated with managing patients undergoing hemodialysis.
Major payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare. The publication provides a comprehensive overview of payer coverage, policy updates, and clinical benchmarks relevant to CPT code 90935. Readers will gain insight into the clinical context of hemodialysis procedures, typical sites of service, and the importance of accurate coding for physician evaluations during dialysis sessions. The summary also highlights common modifiers and associated taxonomies, offering a clear understanding of how this code fits into broader dialysis care and billing practices.
This article is designed to inform healthcare professionals, billing specialists, and policy analysts about the national landscape for CPT code 90935, including payer coverage and clinical application. It serves as a resource for understanding the role of this code in acute hemodialysis care and its significance in medical billing and policy.
CPT Code Overview
CPT code 90935 represents a hemodialysis procedure with a single physician evaluation. This service is categorized under Dialysis Services – Hemodialysis Procedures and is typically performed in a hospital inpatient or outpatient dialysis setting, specifically for acute hemodialysis. The code is used to document and bill for the physician's evaluation during a single hemodialysis session, ensuring accurate tracking of clinical care provided in these settings.
Clinical & Coding Specifications
Clinical Context
A patient with chronic kidney disease, such as end stage renal disease, presents to a hospital outpatient dialysis unit for scheduled hemodialysis. The nephrology physician evaluates the patient before the procedure, reviews laboratory results, assesses fluid status, and determines the dialysis prescription. The patient undergoes a single hemodialysis session, and the physician documents a single evaluation during the treatment. This workflow is typical for acute hemodialysis in hospital settings, where the physician's involvement is limited to one evaluation per session, as described by CPT code 90935.
Coding Specifications
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Modifier
26: Indicates the professional component of the service, used when only the physician's evaluation is billed (not the facility or technical component). -
Modifier
52: Used when the service provided is reduced from the usual protocol, such as a shortened dialysis session or partial evaluation.
| Provider Taxonomy Code | Specialty Name |
|---|---|
207RN0300X | Nephrology Physician |
207R00000X | Internal Medicine Physician |
363LF0000X | Nurse Practitioner |
Related Diagnoses
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N18.6- End stage renal disease- Indicates patients with irreversible kidney failure requiring dialysis, directly relevant to hemodialysis procedures.
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N18.9- Chronic kidney disease, unspecified- Used for patients with chronic kidney disease where the stage is not specified, often requiring ongoing dialysis.
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I12.9- Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease- Represents patients with both hypertension and chronic kidney disease, who may require hemodialysis.
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Z99.2- Dependence on renal dialysis- Identifies patients who rely on dialysis for renal function, supporting medical necessity for the procedure.
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N17.9- Acute kidney failure, unspecified- Used for patients with sudden loss of kidney function, who may require acute hemodialysis in a hospital setting.
Related CPT Codes
90937- Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription
90937 is used when the physician provides multiple evaluations during a single dialysis session or makes significant changes to the dialysis prescription. It is an alternative to 90935 when the clinical situation requires more intensive physician involvement. Typically, only one of these codes is billed per session, depending on the complexity and frequency of physician evaluation.
National Reimbursement Benchmarks
Medicare's national mean rate for CPT code 90935 is $62.81, which is significantly lower than the BUCA (average commercial) mean rate of $96.96. Commercial payers such as Cigna and UnitedHealth Group offer the highest mean rates, at $117.81 and $119.02 respectively, while Aetna and Blue Cross Blue Shield are closer to the BUCA average.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies notably across payers. Medicare exhibits the tightest range at $3.00, indicating minimal variation in rates. In contrast, UnitedHealth Group and Cigna show the widest dispersions, with ranges of $71.00 and $63.00 respectively, reflecting greater variability in commercial reimbursement. The table and chart below present the full breakdown of national benchmarks for each payer.
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