Summary & Overview
CPT 90955: Monthly Pediatric ESRD Management
CPT code 90955 designates monthly comprehensive management of end stage renal disease (ESRD) in pediatric patients aged 2 to 11, requiring two to three face‑to‑face encounters per month. This code captures the ongoing, coordinated clinical management and oversight of dialysis-related and ESRD care for young children who require frequent assessment and intervention. Nationally, accurate use of this code supports appropriate recognition of resource intensity for pediatric ESRD care and aligns billing with the longitudinal responsibilities of providers.
Key payers covered in the analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context for the code, typical sites of service, common modifiers, and payer coverage considerations. The publication outlines benchmarks and coverage patterns where available, explains billing and documentation implications for monthly pediatric ESRD management, and highlights any recent policy clarifications or coding guidance relevant to longitudinal pediatric dialysis care. Data not available in the input is noted where payer-specific rates, payor policies, ICD-10 pairings, and associated taxonomies are not provided.
Billing Code Overview
CPT code 90955 describes monthly comprehensive management of a pediatric patient with end stage renal disease (ESRD) who is between 2 and 11 years of age. The service requires the provider to see the patient face-to-face two to three times during the month to coordinate and deliver all aspects of ongoing ESRD care.
-
Service type: Monthly comprehensive ESRD care management for pediatric patients
-
Typical site of service: Outpatient dialysis clinic or pediatric nephrology clinic where face-to-face visits and coordination of dialysis-related care are provided
Clinical & Coding Specifications
Clinical Context
A typical patient is a school‑aged child (age 2–11 years) with established end‑stage renal disease (ESRD) receiving monthly comprehensive management by a pediatric nephrologist. The provider conducts two to three face‑to‑face visits during the month to assess dialysis access or transplant status, review growth and nutrition, adjust dialysis prescription or medications, coordinate vascular access or peritoneal dialysis supplies, and manage complications such as fluid overload, anemia, electrolyte disturbances, or infections. Visits occur in outpatient dialysis units, pediatric nephrology clinics, or hospital outpatient departments; at least two encounters are face‑to‑face with documentation of assessment, plan, and coordination with dialysis nursing and caregivers. Typical workflow includes review of dialysis logs and lab results, medication reconciliation, physical exam focused on fluid status and access site, ordering or adjusting lab tests and therapies, and care coordination with social work, dietitians, and transplant teams.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
11 | Billing and/or medical direction by physician | Use when the physician is the primary billing provider and not under unusual circumstances |
22 |