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End-stage renal disease (ESRD) related services encompass a comprehensive range of medical care provided to patients aged 20 years and older who are experiencing advanced kidney failure. This care is delivered in an outpatient setting and is designed to manage the complexities associated with ESRD. The primary focus of these services is to ensure that patients receive appropriate dialysis treatment, which is critical for their survival and quality of life. The physician or other qualified health care professional plays a pivotal role in establishing the dialyzing cycle, which involves determining the frequency and duration of dialysis sessions tailored to the individual needs of the patient. In addition to overseeing the dialysis process, the healthcare provider conducts regular evaluations and management services that address both existing and potential medical issues that may arise during the course of treatment. This includes monitoring the patient's health status, responding to new symptoms, and making necessary adjustments to the dialysis prescription based on laboratory data and clinical assessments. The healthcare professional also provides essential follow-up care, which may include telephone consultations to ensure continuity of care throughout the month. Moreover, the management of ESRD involves a multidisciplinary approach, where the physician coordinates with various specialists to address the comprehensive needs of the patient. This may include social services for psychosocial support, nutritional counseling to optimize dietary intake, and planning for potential kidney transplantation. The services rendered under this code are encapsulated in a single monthly billing, reflecting the totality of care provided, which is contingent upon the number of face-to-face visits conducted. Specifically, CPT® Code 90960 is applicable for patients who have had four or more face-to-face visits within a month, ensuring that they receive the necessary oversight and management for their ESRD condition.
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The indications for CPT® Code 90960 include the management and oversight of patients diagnosed with end-stage renal disease (ESRD) who are 20 years of age and older. This code is applicable for patients requiring comprehensive outpatient care that includes regular monitoring and adjustments to their dialysis treatment plan. The following conditions and symptoms may warrant the use of this code:
The procedure associated with CPT® Code 90960 involves several key steps that ensure comprehensive care for patients with end-stage renal disease. The following procedural steps are outlined:
Post-procedure care for patients receiving ESRD related services under CPT® Code 90960 involves ongoing monitoring and support to ensure the patient's health and well-being. After the establishment of the dialysis regimen, patients are expected to have regular follow-up visits to assess their response to treatment and to make any necessary adjustments. The healthcare provider will continue to monitor laboratory results and clinical symptoms, ensuring that any complications are addressed promptly. Patients may also receive additional support services, such as nutritional counseling and social services, to help manage the challenges associated with living with ESRD. Education on self-care practices, medication adherence, and dietary modifications is often provided to empower patients in managing their condition effectively. The overall goal of post-procedure care is to maintain the patient's health, prevent complications, and enhance their quality of life while undergoing treatment for end-stage renal disease.
| Short Descr | ESRD SRV 4 VISITS P MO 20+ | Medium Descr | ESRD RELATED SVC MONTHLY 20&/> YR OLD 4/> VISITS | Long Descr | End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 4 or more face-to-face visits by a physician or other qualified health care professional per month | Status Code | Active Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Items and Services Not Billable to the MAC | Type of Service (TOS) | 1 - Medical Care | Berenson-Eggers TOS (BETOS) | P9A - Dialysis services (Medicare Fee Schedule) | MUE | 1 | CCS Clinical Classification | 227 - Other diagnostic procedures (interview, evaluation, consultation) |
| 95 | Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system. | GW | Service not related to the hospice patient's terminal condition | X2 | Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | AR | Physician provider services in a physician scarcity area | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | V7 | Arteriovenous fistula only (in use with two needles) | G3 | Most recent urr reading of 65 to 69.9 | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | GT | Via interactive audio and video telecommunication systems | V5 | Vascular catheter (alone or with any other vascular access) | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | 24 | Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period: the physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. this circumstance may be reported by adding modifier 24 to the appropriate level of e/m service. | 25 | Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59. | 77 | Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 93 | Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system : synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located away at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. | AF | Specialty physician | AY | Item or service furnished to an esrd patient that is not for the treatment of esrd | CG | Policy criteria applied | FS | Split (or shared) evaluation and management visit | G1 | Most recent urr reading of less than 60 | G4 | Most recent urr reading of 70 to 74.9 | G6 | Esrd patient for whom less than six dialysis sessions have been provided in a month | GQ | Via asynchronous telecommunications system | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | Q5 | Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | QJ | Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b) | QW | Clia waived test | SA | Nurse practitioner rendering service in collaboration with a physician | UJ | Services provided at night | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2013-01-01 | Changed | Description Changed |
| 2011-01-01 | Changed | Short description changed. |
| 2009-01-01 | Added | - |
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