Summary & Overview
CPT 90956: Monthly Management for Pediatric ESRD Patients
CPT code 90956 designates monthly physician management of pediatric patients aged 2 to 11 with end stage renal disease (ESRD), requiring a face-to-face visit at least once in the month. This code captures the clinician’s comprehensive oversight of all services associated with monthly ESRD care for young children and is used across outpatient nephrology and pediatric specialty settings. Nationally, accurate use of this code affects clinical continuity, quality reporting, and appropriate reimbursement for chronic dialysis-related management in pediatric populations.
Key payers in the national landscape include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the code’s clinical intent and service context, typical sites of service, and the payer mix considered in benchmarking. The publication summarizes billing patterns, common modifier usage, and related service lines when available, and highlights policy or coding guidance relevant to monthly ESRD management for pediatric patients. Data not provided in the input—such as specific ICD-10 pairings, taxonomies, or related CPT links—is noted as not available in the input.
Billing Code Overview
CPT code 90956 describes monthly management of care for a pediatric patient with end stage renal disease (ESRD) aged 2 through 11 years. The service represents the provider's coordination and oversight of all services related to the patient’s monthly ESRD care, with a requirement that the provider see the patient face-to-face at least once during the month.
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Service type: Monthly physician or practitioner management and coordination of ESRD care for pediatric patients
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Typical site of service: Outpatient clinic or other face-to-face ambulatory setting where monthly evaluation and care coordination can be performed
Clinical & Coding Specifications
Clinical Context
A typical patient is a pediatric child aged 2–11 years with end stage renal disease (ESRD) receiving maintenance dialysis and enrolled in a monthly comprehensive management program. The nephrology provider coordinates all aspects of ESRD care during the month, including medication adjustments, growth and nutritional surveillance, vascular access assessment, laboratory review (electrolytes, hemoglobin, dialysis adequacy), immunization and transplant evaluation updates, psychosocial and family education, and coordination with dialysis center staff and pediatric subspecialists. The provider performs at least one face-to-face visit with the patient during the month to assess clinical status, document the monthly plan of care, and address any acute issues. Typical workflow includes chart review of dialysis logs and labs, communication with dialysis nurses, a clinic or dialysis-unit visit for the face-to-face encounter, documentation of the monthly summary and plan, and submission of the monthly ESRD management service code for billing purposes. Payors involved may include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare depending on patient coverage.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
11 | Professional Component | When reporting the physician’s professional work separate from technical services (rare for this monthly management code). |