The ESRD Monthly Capitation Payment in Medical Billing: 90951 to 90970

The ESRD monthly capitation payment (MCP) is the one payment Medicare makes each calendar month to the physician or practitioner managing a patient on maintenance dialysis. It replaces separate visit charges for most outpatient care related to the patient’s end-stage renal disease. For in-center patients the code depends on the patient’s age and how many face-to-face visits happened in the month.

Nephrology billing repeats every month: the same patient and the same code family. Most errors happen in the months that are not routine.

Where you see it

Place	What it shows
CMS-1500 box 24A or 837P DTP service dates	A from and to date spanning the calendar month, or the span of days the physician was responsible
CMS-1500 box 24D	One monthly code (90951 to 90966) or one per-day code (90967 to 90970)
CMS-1500 box 24G or 837P SV104	Units: 1 for a monthly code, the number of days for a per-day code
CMS-1500 box 32 and 32a	The dialysis facility’s name, address and NPI
CMS-1500 box 21	N18.6 (end stage renal disease), with Z99.2 (dependence on renal dialysis) as an additional code
Medicare Physician Fee Schedule RVU file	All of these codes are global XXX, status A, with no professional or technical split

The codes

Patient age at month end	4 or more visits	2 to 3 visits	1 visit	Home dialysis, full month	Less than a full month, per day
Under 2	90951	90952	90953	90963	90967
2 to 11	90954	90955	90956	90964	90968
12 to 19	90957	90958	90959	90965	90969
20 and older	90960	90961	90962	90966	90970

For in-center patients the lowest payment is one visit, a higher payment is two or three, and the highest needs at least four ESRD-related visits in the month. Home dialysis patients are paid a single monthly rate by age, regardless of the number of visits, but the MCP physician must furnish at least one face-to-face visit a month, and the documentation should show it. A MAC may waive that visit case by case when the notes show the physician actively managed the patient through the month.

Visits must be face-to-face by a physician, nurse practitioner, physician assistant or clinical nurse specialist. The MCP physician may use partners or employees of the same group for some visits without being present. Visits to patients in observation status or living in a skilled nursing facility count. Inpatient hospital visits do not.

What the month includes

The Medicare Claims Processing Manual, Chapter 8, section 140, lists the services inside the MCP: the dialysis prescription and its adjustments, dietary and fluid assessment, anemia and erythropoietin management, bone and mineral management, review of adequacy measures, periodic visits during dialysis, access assessment, review of the care plan with staff, and certification of durable medical equipment and home health. Care plan oversight (99375) is inside the MCP and is never billed separately.

Paid separately under the fee schedule: hepatitis B vaccine administration, surgical services such as dialysis catheter placement and access repair, test interpretations with a professional component (electrocardiograms, echocardiograms, biopsies), the complete transplant evaluation, home dialysis training, inpatient services, and physician services for conditions unrelated to the renal disease, with documentation that the illness is unrelated and the visit was needed. Services before outpatient dialysis began are not part of the MCP either.

The month, the age and the first month

A month is a calendar month. In the first month of dialysis the dates of service run from the day dialysis started through the end of that month. Age is the patient’s age on the last day of the month, so a patient who turns 20 on the 28th is billed in the 20-and-older band.

Medicare pays 80 percent of the approved amount after the Part B deductible, and the patient owes the 20 percent coinsurance, every month.

Less than a full month

The per-day codes are for four situations only: a home dialysis patient managed for less than the full month, a transient patient away from home, a partial month in which visits occurred without a complete assessment because the patient was hospitalized, died or received a transplant, and a permanent change of MCP physician during the month. Bill one unit per day the physician was responsible, with the first and last dates as the service dates, and non-continuous spans on separate lines. The per-day codes may not be used to bill a full month in which no complete assessment was done.

Hospitalization does not by itself reduce the MCP. If the MCP physician furnished a complete monthly assessment and the visits, the monthly code is billed by visit count. Inpatient visits during the stay are billed separately by whoever made them, as inpatient visits. A home dialysis patient who dialyzes in-center for part of the month, or switches from center to home, is billed with the home dialysis monthly code for the whole month.

Medicare’s contractors must pay only one MCP per patient per month, after the month has passed, and must deny duplicate MCP claims and separate charges for services the MCP already covers.

Worked example: four months of one patient

Mr. Patel, 66, dialyzes in-center. His nephrologist, Dr. Nair, is the MCP physician. The national 2026 amounts are RVUs times 33.4009, before geographic adjustment and sequestration, so treat them as illustrative. His deductible is met.

Month	What happened	Code and units	National allowed	Medicare 80 percent	Patient 20 percent
May	Complete assessment May 2, visits May 9, 16 and 23	90960 x 1, dates May 1 to May 31	372.75	298.20	74.55
June	Complete assessment June 3; hospitalized June 10 to 20; visit June 25	90961 x 1 (2 visits), dates June 1 to June 30	310.63	248.50	62.13
July	One visit with complete assessment July 8; patient visits family in Arizona July 15 to 31 and dialyzes there	Dr. Nair: 90962 x 1. The Arizona nephrologist: 90970 x 17, dates July 15 to July 31	215.10 and 170.34	172.08 and 136.27	43.02 and 34.07
August	Switches to home hemodialysis August 18 after training	90966 x 1, dates August 1 to August 31	310.30	248.24	62.06

In June, the hospitalist who saw Mr. Patel on June 12 bills a subsequent hospital visit on her own claim. The hospital stay does not turn Dr. Nair’s month into per-day codes because the complete assessment was done. In July, both physicians are paid because the transient patient’s care was split by responsibility, not by visit. In August the home code pays the whole month even though the patient was in-center for 17 days.

What to do

• Build the month’s claims from the roster, not from encounters. One line, one unit, dates spanning the month. A claim for each visit will deny as a duplicate.
• Count visits before choosing the code. Four or more, two or three, or one. Check that each counted visit was face-to-face and by a qualified practitioner in the group, and that none were inpatient days.
• Use age at month end. Birthdays near the end of the month change the band.
• Hold the claim until the month closes. Medicare does not pay the MCP in advance, and the visit count is not known until the last day.
• Code N18.6 first and Z99.2 with it. Keep the dialysis facility’s NPI in box 32a.
• Denials to recognize: CARC 18 (exact duplicate) when a second MCP line reaches Medicare for the same month, and CARC B20 (service furnished by another provider) when another physician was already paid the month; both need the two offices to agree who did the complete assessment, and the other bills per-day. CARC 97 on a dialysis-related office visit means it was inside the MCP; write it off unless the visit was for an unrelated condition, in which case resubmit with documentation and modifier 25 where the visit fell on a dialysis day.
• In Iridium Suite’s treatment-course workflow for nephrology practices, the diagnosis code stays attached to a dialysis patient until a staff member changes it, so each new service line is billed without re-keying the diagnosis.

Related terms

• Coordination of benefits
• Medicare crossover claims
• Place of service codes
• CMS-1500 box by box
• Medically Unlikely Edits
• 2013 ESRD payments and incentives
• Medicare Secondary Payer and the ESRD 30-month coordination period

Further reading: Medicare Claims Processing Manual, Chapter 8, sections 140 to 140.4 (the monthly capitation payment) and 160 to 170 (inpatient dialysis services); CMS PFS Relative Value Files (RVUs and indicators for 90951 to 90970); CMS FY 2026 ICD-10-CM code descriptions (N18.6 and Z99.2); NCCI Policy Manual for Medicare Services, 2026, Chapter XI (dialysis and evaluation and management services).