Summary & Overview
CPT 90962: Monthly Management Visit for Adult ESRD Patients
CPT code 90962 denotes the monthly management service for adults (age 20 and older) with end stage renal disease (ESRD), requiring the provider to perform a single face-to-face encounter each month to manage all aspects of the patient’s ESRD care. This code matters nationally because ESRD affects a significant population that requires ongoing, coordinated services — accurate coding of monthly management encounters supports appropriate clinical oversight and affects payment and quality measurement across facilities that provide dialysis and related care. Key payers referenced in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical context for monthly ESRD management, how CPT code 90962 is used in practice, and what to expect from payer coverage and billing patterns. The publication summarizes benchmark considerations, common billing modifiers, and practical coding notes where available. Data not available in the input will be noted explicitly. The focus is national: clinicians, coding professionals, and policy analysts will gain clarity on the service scope and typical sites of care associated with CPT code 90962 and guidance on topics commonly reviewed during audits and payer contract discussions.
Billing Code Overview
CPT code 90962 describes monthly management of all services for an adult patient (age 20 or older) with end stage renal disease (ESRD). The provider is responsible for coordinating and delivering comprehensive care related to the patient’s ESRD and must see the patient face-to-face one time during the month to accomplish this care.
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Service type: Monthly ESRD comprehensive management visit
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Typical site of service: Outpatient dialysis center or other ambulatory care setting where ESRD maintenance and monthly oversight occur
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 65-year-old patient with end stage renal disease (ESRD) receiving maintenance hemodialysis presents for routine monthly management by the nephrology provider. The provider coordinates all aspects of the patient’s ESRD care for the month — reviewing dialysis adequacy, access status, vascular access examinations, laboratory trends (electrolytes, hemoglobin, calcium, phosphorus), medication adjustments (erythropoiesis-stimulating agents, phosphate binders, antihypertensives), nutrition counseling, and scheduling any needed procedures. The provider performs one documented face-to-face visit during the month with the patient, either at the dialysis facility or in the outpatient clinic, to meet the requirement for 90962. Clinical workflow includes chart review of dialysis records, medication reconciliation, lab review, a focused physical exam (including access inspection), counseling and documentation of the monthly plan of care, and communication with the dialysis center staff to implement changes.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
11 | Normally processed as defined by payer | Use when the service is an office visit provided by the primary billing provider without unusual circumstances. |