Summary & Overview
CPT 90952: Monthly Management of Pediatric End Stage Renal Disease
CPT code 90952 denotes monthly physician management of end stage renal disease (ESRD) for patients under age 2, requiring two to three face-to-face visits per month. This code captures comprehensive, ongoing care coordination and clinical management for a high-acuity pediatric population. Nationally, accurate use of this code matters for appropriate payment, care continuity, and resource planning for pediatric dialysis and ESRD programs.
Key payers referenced include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication outlines payer coverage patterns, billing benchmarks, common modifiers in payer policies, and clinical context for utilization of 90952.
Readers will learn where 90952 fits within pediatric ESRD service lines, the typical sites of service where this work occurs, and what billing teams need to document to support monthly comprehensive management that includes multiple face-to-face encounters. The report also summarizes common policy considerations and billing practice implications at a national level. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 90952 describes the monthly management of all services for a patient younger than 2 years with end stage renal disease (ESRD). The billing definition specifies that the provider performs face-to-face visits with the patient two to three times during the month to deliver comprehensive ESRD care.
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Service type: Ongoing monthly physician management of pediatric ESRD care
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Typical site of service: Ambulatory clinic or hospital outpatient setting with direct face-to-face visits
Clinical & Coding Specifications
Clinical Context
A typical patient is an infant younger than 2 years diagnosed with end stage renal disease (ESRD) receiving chronic dialysis care. The pediatric nephrologist or pediatric dialysis team is responsible for coordinating monthly management, which includes two to three face-to-face visits each month with the patient and caregiver to assess growth, fluid and electrolyte status, vascular access or peritoneal dialysis catheter function, medication adjustments (including immunizations and erythropoietin), nutrition and developmental needs. The workflow includes review of dialysis session records, laboratory results, medication reconciliation, assessment for complications (infection, access dysfunction, hypertension), caregiver education, coordination with the pediatric dialysis unit or home dialysis team, and documentation of face-to-face encounters and care plan updates. Visits often occur in an outpatient pediatric nephrology clinic, dialysis unit, or during coordinated home dialysis visits when applicable. Communication with nephrology nursing, social work, nutrition, and transplant evaluation teams is part of the monthly management cycle.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier | Standard reporting when no modifier applies |
22 |