Summary & Overview
CPT 90958: Monthly ESRD Management for Adolescents
CPT code 90958 denotes monthly comprehensive management of end stage renal disease (ESRD) for adolescents aged 12 to 19 who require coordinated outpatient care. It matters nationally because ESRD management carries substantial clinical complexity, utilization of specialty services, and coordination needs across nephrology, dialysis teams, and supportive care — making accurate coding important for care continuity and payment. Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will learn the clinical scope and service setting for 90958, common modifiers used in practice, payer coverage considerations, and how this code fits into ESRD care delivery. The publication outlines typical site-of-service implications for outpatient clinics and dialysis centers, clarifies patient age criteria and encounter frequency expectations, and summarizes how 90958 is applied in monthly care reporting. Data not available in the input for associated taxonomies, specific ICD-10 mappings, related CPT codes, and detailed payer policy variations.
Billing Code Overview
CPT code 90958 describes the monthly management of all services for a patient aged 12 to 19 years with end stage renal disease (ESRD). The reporting provider assumes responsibility for coordinating and delivering comprehensive ESRD care over a calendar month and must see the patient face-to-face two to three times during that month to accomplish this care.
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Service type: Monthly comprehensive ESRD management for adolescent patients
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Typical site of service: Outpatient specialty clinic or dialysis center where face-to-face encounters can occur
Data not available in the input for payers, associated taxonomies, ICD-10 diagnoses, related codes, and service line.
Clinical & Coding Specifications
Clinical Context
A typical patient is a 16-year-old adolescent with end stage renal disease (ESRD) receiving monthly comprehensive management by a nephrology provider who coordinates dialysis access, medication adjustments, growth and developmental monitoring, and psychosocial support. The provider performs two to three face-to-face visits during the month with documentation of assessment, plan, and coordination of care. Visits may occur in an outpatient nephrology clinic, pediatric dialysis center, or hospital-based pediatric renal clinic. The clinical workflow includes review of dialysis logs and laboratory results, physical exam focused on vascular access and fluid status, medication reconciliation (e.g., erythropoiesis-stimulating agents, phosphate binders, antihypertensives), counseling on nutrition and school participation, and documentation of multidisciplinary communications with social work, dietitians, and dialysis nursing. Billing uses 90958 for the monthly ESRD management for patients aged 12–19 when the provider performs the required 2–3 face-to-face visits and manages all related services during that month.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | Use when billing only the professional component of a service if applicable in split-component scenarios |