Nephrology Billing and Coding Guidelines

Every year, new codes and billing regulations are released that nephrology practices must adhere to. The nephrology billing and coding guidelines are created to ensure compliance with regulations and the financial stability of the healthcare organization.

To streamline your nephrology practice’s billing and coding, you should be familiar with the key components of the processes and utilize strategies to improve them. As experts in the field, we are here to assist you in your journey, whether it is with a comprehensive guide like this one or with our medical billing and coding services.

Understanding Nephrology Billing and Coding Guidelines

The wide set of nephrology billing and coding guidelines includes specific rules for coding, document collection, claim submission, and management that must be followed by nephrologists. Adherence to these guidelines ensures compliance with healthcare regulations and contributes to accurate reimbursement.

The reimbursement process in nephrology involves several crucial steps, such as coding and claim preparation, claim submission and management, handling denied claims, and obtaining funds from the payor, which typically is the insurance carrier.

Compliance with Regulatory Requirements

Staying compliant with healthcare regulations is essential for avoiding penalties. Some of the basic regulations you, as a nephrology service provider, must adhere to include HIPAA, Medicare guidelines, and payer-specific rules.

The nephrology billing and coding guidelines are established by organizations like the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS).

To ensure compliance, your practice should focus on several aspects:

  • Staying up to date with policy changes
  • Meeting documentation requirements
  • Utilizing correct nephrology billing codes

Documentation Best Practices

One of the key components of nephrology billing and coding is gathering detailed documentation. Essential documentation for medical billing includes:

  • Patient’s personal and insurance data
  • Medical history
  • Physical and lab examination results
  • Medical decision-making process
  • Time spent counseling

Nephrology also requires more specific documentation than other medical fields, which include:

  • Care onset
  • Initial diagnosis and care plan
  • Anatomical site specificity
  • Laterality or details on the affected side
  • Etiology and manifestation (documentation of underlying causes and observable conditions)
  • Records indicating the disease severity
  • Combination codes
  • Utilizing specified and unspecified combination codes
  • Notes for any complicating or aggravating conditions

In addition to collecting the required documentation, it is important to include specific terms and phrases to highlight the condition of the patient, medical necessity, and the procedure’s complexity. The documents must be written in clear and concise language to avoid misinterpretation by the insurance carriers.

When it comes to enhancing documentation efficiency, different strategies can be utilized. It could be something as simple as providing continuous training and education for medical billers and coders or using electronic health record (EHR) systems and offering templates and guiding prompts.

Coding Guidelines Specific to Nephrology

The complex nephrology coding process requires advanced knowledge and skills. Proper navigation, usage of codes and modifiers, and timely claims submission will ensure maximum reimbursement for the services you have provided.

In nephrology, CPT and ICD-10 codes are used, along with modifiers in special circumstances. The ICD-10 codes are strictly for diagnosis, while the CPT codes are procedure codes for identifying surgical, medical, and diagnostic interventions.

CPT codes in nephrology

The CPT codes are divided into different categories according to the specific type of procedure, making navigation through them easier. For instance, the CPT codes for dialysis range from 90951 to 90970, while the ones for surgical kidney procedures are from 50010 to 50593.

Bear in mind that the Americal Medical Association releases/updates a new CPT code set annually. Every medical biller must keep up with the changes to stay compliant and accurately translate the procedures into codes.

ICD-10 codes for nephrology

The ICD-10 is an international set of codes from the World Health Organization used specifically for diseases. The codes for diseases of the genitourinary system range from N00 to N99. To illustrate, chronic kidney diseases are coded with N18 and divided into stages from N18.1 to N18.5.

Other commonly used ICD-10 codes in nephrology billing are:

  • N21 for calculus of the lower urinary tract
  • N30-N39 for other urinary system diseases
  • Y84.6 for urinary catheterization
  • S37 for injuries to urinary and pelvic organs
  • Z46.6 fitting and adjustment of urinary device

Common errors in nephrology coding

Some of the mistakes medical coders make when coding nephrology services include:

  • Inaccurate or incomplete coding
  • Missing documentation
  • Upcoding
  • Downcoding
  • Unbundling services
  • Failure to prove medical necessity
  • Submitting claims with unspecified diagnosis

Claim denials and financial losses might arise if some of these nephrology billing errors are made.

Streamlining Billing Processes

Coding complexities make the nephrology billing services more complex than other specialties. In nephrology, different reimbursement methodologies can be utilized, such as:

  • Value-based care reimbursement for emphasizing healthcare quality and standards above service volume
  • Fee-for-service reimbursement for prioritizing service volume
  • Bundled payments to billing for different services but getting a single payment
  • Medicare and Medicaid claim submission as major payers in nephrology,
  • Private insurance reimbursement
  • Capitation billing as a proactive and preventive measure by setting monthly payments for each patient.

In nephrology, alternative payment models are available such as telehealth services and shared saving programs.

To achieve an efficient billing workflow for nephrology practices, maximizing revenue and reducing billing errors, its recommended to utilize billing software and implement Electronic Health Records. Most importantly, billing software and EHR might reduce errors and denied claim rates.

Outsourcing Solutions By CLICKVISION BPO

Nephrology billing and coding impose many challenges and can be an administrative burden to a healthcare facility. Consequently, many decide to outsource medical billing and coding.

By outsourcing nephrology billing to CLICKVISION BPO, you can rest assured that you will receive accurate coding, reduced denial rates, and timely reimbursement. Compared to many in-house coding and billing teams, we offer cost-effective solutions while maintaining the highest quality.

We are an entirely transparent and reliable company that many healthcare facilities trust. Our priority is to streamline your revenue cycle management by following the latest nephrology billing and coding guidelines.

Outsourcing Solutions


Following the nephrology billing and coding guidelines is essential for continuous improvement, reduced claim denial rates, and financial stability. Compliance can be achieved by keeping up with the latest policy changes, gathering needed documentation, and using accurate billing codes. If your nephrology practice is interested in streamlining your medical billing and coding process, don’t hesitate to contact us and see why we are among the best companies for outsourcing.