Summary & Overview
CPT 90947: Dialysis Procedure Other Than Hemodialysis, Repeated Evaluation
CPT code 90947 covers dialysis procedures other than hemodialysis, including peritoneal dialysis and hemofiltration, when repeated evaluations are required. This code is significant for hospitals and nephrology practices nationwide, as it addresses complex cases where ongoing assessment and potential revision of the dialysis prescription are necessary. The procedure is most commonly performed in inpatient hospital settings, with evaluation and management services bundled into the billing.
Major national payers such as Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare recognize and reimburse for CPT code 90947. The publication provides a comprehensive overview of payer coverage, clinical indications, and billing benchmarks for this code. Readers will gain insight into policy updates, typical clinical scenarios, and how this code fits within the broader context of dialysis services. The summary also highlights related codes and modifiers, offering clarity on distinctions between various dialysis procedures and their documentation requirements.
Healthcare professionals and administrators will find this resource valuable for understanding the clinical and billing landscape of dialysis services beyond hemodialysis, ensuring accurate reporting and compliance with payer policies.
CPT Code Overview
CPT code 90947 is used to report dialysis procedures other than hemodialysis, such as peritoneal dialysis or hemofiltration, that require repeated evaluations. This code applies whether or not there is substantial revision of the dialysis prescription during the course of treatment. The service type is classified as Miscellaneous Dialysis Services and Procedures, and it is typically performed in an inpatient hospital setting, where evaluation and management services are bundled.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves an adult admitted to an inpatient hospital setting with acute or chronic renal failure, fluid overload, or significant electrolyte disturbances such as hyperpotassemia or acidosis. The patient is not a candidate for hemodialysis due to clinical factors or preference. The nephrology or internal medicine physician evaluates the patient repeatedly throughout the day, adjusts the dialysis prescription as needed, and oversees a dialysis procedure other than hemodialysis (e.g., peritoneal dialysis or hemofiltration). The service is bundled with evaluation and management (E/M) in the inpatient setting, and may require substantial revision of the dialysis plan based on ongoing clinical assessments.
Coding Specifications
- Modifier
25: Used to indicate a significant, separately identifiable evaluation and management service by the same physician on the same day as the dialysis procedure. This is applicable when the physician provides an E/M service that is distinct from the dialysis procedure.
| Provider Taxonomy Code | Specialty |
|---|---|
207RN0300X | Nephrology Physician |
208800000X | Urology Physician |
207R00000X | Internal Medicine Physician |
- Nephrology Physician: Specializes in kidney diseases and dialysis management.
- Urology Physician: Manages urinary tract and kidney disorders, may oversee dialysis in certain cases.
- Internal Medicine Physician: Provides comprehensive care for adults, including management of complex medical conditions requiring dialysis.
Related Diagnoses
E83.40– Disorders of magnesium metabolism: Relevant for patients with abnormal magnesium levels requiring dialysis to correct electrolyte imbalances.E83.41– Disorders of magnesium metabolism: Indicates specific magnesium disorder, often managed with dialysis.E83.42– Disorders of magnesium metabolism: Another variant of magnesium disorder, may necessitate dialysis intervention.E83.49– Disorders of magnesium metabolism: Other specified magnesium disorders, dialysis may be required for management.E83.30– Disorders of phosphorus metabolism: Phosphorus imbalance is common in renal failure, managed with dialysis.E83.31– Disorders of phosphorus metabolism: Specific phosphorus disorder, dialysis helps regulate levels.E83.32– Disorders of phosphorus metabolism: Another phosphorus disorder, dialysis indicated for correction.E83.39– Disorders of phosphorus metabolism: Other specified phosphorus disorders, dialysis may be part of treatment.E87.1– Hyposmolality and/or hyponatremia: Dialysis is used to correct severe sodium and osmolality disturbances.E87.2– Acidosis: Metabolic acidosis is a common indication for dialysis.E87.70– Fluid overload disorder: Dialysis is used to remove excess fluid in cases of overload.E87.79– Fluid overload disorder: Other specified fluid overload, managed with dialysis.E87.5– Hyperpotassemia: High potassium levels are life-threatening and often require urgent dialysis.E87.8– Electrolyte and fluid disorders not elsewhere classified: Dialysis is used for complex electrolyte disturbances.I50.9– Congestive heart failure, unspecified: Fluid overload in heart failure may necessitate dialysis.I50.1– Left heart failure: Dialysis may be used to manage fluid retention in left heart failure.I50.20– Systolic heart failure, unspecified: Dialysis indicated for fluid and electrolyte management.I50.23– Acute on chronic systolic heart failure: Dialysis may be required for acute decompensation.N19– Renal failure, unspecified: Primary indication for dialysis procedures.R60.0– Edema: Dialysis used to treat significant edema.R60.1– Edema: Another form of edema, managed with dialysis.R60.9– Edema: Unspecified edema, dialysis may be indicated.R06.02– Shortness of breath: Symptom of fluid overload or heart failure, managed with dialysis.R41.82– Altered mental status: May result from severe electrolyte or fluid imbalance, dialysis indicated for correction.
Related CPT Codes
| CPT Code | Description | Clinical Relationship |
|---|---|---|
90945 | Dialysis procedure other than hemodialysis with single physician evaluation | Used for similar dialysis procedures but with only one evaluation per day; alternative to 90947 when repeated evaluations are not required. |
90935 | Hemodialysis procedure with one evaluation | Used for hemodialysis with a single evaluation; not applicable for peritoneal or hemofiltration procedures. |
90937 | Hemodialysis with repeated evaluation | Used for hemodialysis with repeated evaluations; analogous to 90947 for hemodialysis. |
90997 | Hemoperfusion | Used for hemoperfusion procedures, which are distinct from dialysis but may be considered in similar clinical scenarios. |
90999 | Dialysis procedure | Used for dialysis procedures not otherwise specified; may be used when no specific CPT code applies. |
- Codes
90945and90947are alternatives depending on the frequency of physician evaluation. - Codes
90935and90937are specific to hemodialysis, not peritoneal or hemofiltration. - Code
90997is for hemoperfusion, which is a separate extracorporeal therapy. - Code
90999is used for miscellaneous dialysis procedures when other codes do not fit.
National Reimbursement Benchmarks
For CPT code 90947, the national mean rate for Medicare is $108.33, which is significantly lower than the BUCA (Blue Cross Blue Shield, UnitedHealth Group, Cigna, and Aetna) average commercial mean rates. Among commercial payers, UnitedHealth Group has the highest mean rate at $203.31, while Aetna is the lowest at $127.60. The BUCA mean rate stands at $166.87, highlighting a substantial gap between Medicare and commercial reimbursement levels.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies notably across payers. Medicare exhibits the tightest range at $5.00, indicating minimal variation in rates. In contrast, UnitedHealth Group and Cigna show the widest dispersions, with ranges of $120.59 and $108.50 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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