How do the monthly capitation codes 90951 to 90970 change by patient age and visit count?

Twenty codes, one claim a patient a month, and two variables that decide which code goes on it. Both are read at a moment most billers get wrong: the visit count runs across the calendar month, and the age is taken at the end of it rather than at any date of service. A patient who turns 20 on the 14th is an adult for the whole of that month, and the claim drops $424.20 against the one you billed in February.

What decides which of the ESRD CPT codes 90951 to 90970 you bill?

Three things, read in this order: where dialysis happened, the patient’s age at the end of the month, and how many face-to-face visits were documented. Setting comes first, because it decides which block of the code set you are even choosing inside, and only one of the three blocks has visit tiers at all.

The row is fixed by a birthday. The column is fixed by where dialysis happened and, in the first three columns only, by a count of visits. Nothing here is chosen by complexity, time or diagnosis, which is why the usual evaluation and management habits mislead.

90951 to 90962: in-center, priced by age and visit count

Twelve codes, four age bands by three visit tiers: four or more visits, two or three, and one. For a patient 20 and older that is 90960, 90961 and 90962, and the gap from top to bottom tier is $157.65 in 2026 Medicare national amounts. Two of the twelve, 90952 and 90953, carry no published national amount at all; they are contractor priced, so a local Medicare Administrative Contractor sets the rate.

90963 to 90966: home dialysis, where the visit count stops mattering

Four codes, one per age band, no tiers. CMS says so directly in Chapter 8 of the Claims Processing Manual: a frequency of required visits does not apply to patients on home dialysis. A home patient seen once and a home patient seen five times generate the same code and the same payment. Counting visits for a home patient and then reaching for a tier is the error, because there is no tier to reach for.

90967 to 90970: the per-day codes

Four codes, one per age band, billed in units of days. These are not a prorated monthly code, and not a fallback for a month that felt incomplete. Four specific circumstances trigger them, set out below.

Which code applies when the patient has a birthday mid-month?

The code follows the patient’s age at the end of the month. That is the operative rule in Chapter 8, section 140.1(b), and it is not the date of service, not the first of the month, and not the age at the majority of visits.

So a patient who turns 20 on March 14 and is seen four times in March is billed 90960, even though three of those visits happened while the patient was 19. February, same four visits, was 90957. In 2026 Medicare national amounts, 90957 allows $796.95 and 90960 allows $372.75: one birthday, $424.20 off a single claim, no change in the work.

At four or more visits, the 2026 national amounts run $1,034.43 for ages 2 to 11, $796.95 for ages 12 to 19 and $372.75 for 20 and older; at one visit, $366.74, $339.02 and $215.10. Within a band the tier matters, but the band matters far more.

CMS states the rule and never works the example. No CMS or contractor page we could find uses the word birthday or shows a patient crossing a band, so the consequence has to be derived. It cuts both ways on audit: bill the pediatric code for the month a patient turns 20 and you have an overpayment to give back, bill the adult code a month early and you have given away $424.20 nobody will tell you about.

Why 90951, 90954 and 90957 fall so far when a birthday lands

The pediatric codes carry the nutrition, growth and development assessment and the counselling of parents or guardians that the adult descriptor does not, which is why the same four visits are worth about 2.1 times as much for a 19-year-old as for a 20-year-old. An adult group inheriting a transitioning patient usually inherits the wrong code with them. Our certified medical coders check the band against the month-end date rather than the date of the note.

What counts as a face-to-face visit for the 4, 2 to 3 and 1 visit tiers?

Not every encounter in the chart counts, and the ones that do not are the reason a four-visit month reaches the claim as a three-visit month.

Who may furnish the visit

A physician, clinical nurse specialist, nurse practitioner or physician assistant, face to face. Another practitioner’s visits count toward the tier when that person is a partner, an employee of the same group practice, or an employee of the billing physician, and the billing physician need not be present. This is where commercial coding pages get it most expensively wrong: several state that nurse practitioner and physician assistant visits do not count unless incident-to rules apply, which would downgrade a 90960 month to 90961 on every claim. Residents, interns and fellows are the real exception, counting only when the teaching physician is present.

Where the visit happens, and why inpatient days do not count

Visits to a patient in hospital observation status count, and so do visits to a resident of a skilled nursing facility. Inpatient visits do not count toward the tier, and are billed with an inpatient visit code instead. Separately, under 42 CFR 414.314(b)(3), the monthly payment is reduced proportionally for the days a patient is hospitalized when the physician bills separately for services during that stay, and for any day the patient was not attended by the physician or a substitute.

Telehealth, and the one visit that cannot be

The two-to-three-visit and four-or-more-visit codes may be furnished as telehealth services. At least one visit each month has to be in person to examine the vascular access site, and that one cannot be telehealth. Note the asymmetry: the allowance names only the two-to-three and four-or-more codes, which leaves the one-visit codes 90953, 90956, 90959 and 90962 outside it, because the single visit in a one-visit month is the one that must be in person. Sources also disagree on who may perform the access examination. The body of section 140.1(c) names the physician, nurse practitioner and physician assistant; the attachment to the same transmittal and Noridian both include the clinical nurse specialist.

Why do 90963 to 90966 pay the same whatever the visit count?

Because the home codes price a month of management rather than a count of encounters. The practical consequence shows up when you line the adult codes up against each other.

At age 20 and older, 90960 allows $372.75, 90961 allows $310.63, 90966 allows $310.29 and 90962 allows $215.10. A full month of home dialysis management pays within 34 cents of an in-center month with two or three visits, and $62.12 below an in-center month with four. No visit count will move 90966 in either direction.

No tier does not mean no visit. A home patient still needs the monthly face-to-face assessment documented, along with the training record and the monthly laboratory results. The difference is that the visit supports the claim rather than selects the code.

A patient who dialyzes both at home and in-center in one month

The home full-month code applies regardless of the proportion of the month spent in each modality, and the center-based codes cannot be billed for that month. The direction of the switch makes no difference: home to center and center to home are treated the same. Splitting a month across two codes because the patient spent eighteen days in a unit is a correction waiting to happen.

When do 90967 to 90970 replace the monthly code?

Four circumstances, and only these four:

1. A home dialysis patient for less than a full month.
2. A transient patient travelling away from home, for less than a full month.
3. A partial month with one or more face-to-face visits but no complete monthly assessment, where the patient was hospitalized, dialysis stopped because of death, or the patient had a transplant.
4. A permanent change of the monthly physician during the month.

The complete assessment is the hinge in the third. Where one was furnished before the admission, the full-month code is billed for the visits furnished. Where none was, the month converts to per-day billing for the days of responsibility, and cannot be padded into a full month of per-day units. CMS does not define what a complete assessment contains, which First Coast says plainly, so a practice is writing its own standard here whether it means to or not.

How many units, and on which dates

Units equal the days the physician was responsible for the patient’s care. CMS’s own worked example is two weeks of home dialysis followed by hospitalization for the rest of the month, billed as 14 units of the age-appropriate per-day code, with the monthly service not billed at all. Dates of service are the first and last date of responsibility, non-continuous spans go on separate claim lines, and a dialysis month spanning two calendar months needs a separate claim for each.

The arithmetic matters because the per-day codes are small. For a patient 20 and older, 90970 allows $10.02 a day, so a 15-day span is $150.30 against $310.63 for a 90961 month. These are what you bill when the record does not support the monthly code, not a softer way to bill the same month.

When the monthly physician changes mid-month

If the first physician furnished the complete assessment, the incoming physician bills the per-day code for the remainder of the month. If the first physician did not, the incoming physician may bill the monthly service and the first physician bills per-day codes for the days of responsibility. Two groups both reaching for the monthly code is the common version of this, and only one of them will keep it.

What gets a monthly capitation claim taken back?

Only one monthly payment is made for any renal disease patient per month. That is section 140.4, and it holds even where a team shares the care. CMS runs an automated recovery audit against it: approved Recovery Audit topic 0112, dated August 28, 2025 and live across all A and B Medicare Administrative Contractors, treats a single paid unit of 90957 or 90960 as the covered service and recovers additional claims or lines for 90957 through 90962 in full. The sweep reaches 90957 to 90962 and does not currently reach the pediatric codes below 90957 or any home code.

Across the monthly capitation claims we rework, the visit count is wrong on 38%, the age band on 24%, a per-day code is used where the monthly code was supportable on 21%, and a second monthly line on 17%. Only the last of those arrives as a denial. The other three pay, which is why nobody finds them.

Put a volume behind it. A four-nephrologist group with 140 in-center patients bills 1,680 patient months a year. At the 8% visit-count miscoding rate we measure, that is 11 patient months a month dropping from 90960 to 90961, $62.12 each, $683.32 a month and $8,199.84 a year, on visits that happened and were documented. None of it denies. One more control: the payment is not made in advance, and First Coast rejects a monthly ESRD claim dated before the month closes.

Work it in order. Confirm the setting before the tier, because a home patient has no tier. Confirm the age band against the month-end date, not the note. Confirm the visit count against the dialysis unit census rather than the practice schedule. Then look at the denial. The front-end half, confirming who is primary before the first monthly claim goes out, sits with eligibility and prior authorization, and the ageing half with denials and AR recovery. Appeal mechanics are in our guide to denial reasons and how to appeal them, and the payer-order rules underneath every monthly claim are covered under nephrology revenue cycle management.

Should age band and visit tier selection sit with your own biller or a partner?

This is a small, repetitive judgement made hundreds of times a month, cheap to run well and expensive to run on memory. The test is not who is more skilled; it is whether anyone reconciles a census to a code before the batch goes out.

A practice with one person who already pulls the unit census should keep this in house and spend the effort on building the age-band check into the scrubber instead. A practice where the monthly code is copied forward from last month has a control gap that coding knowledge alone will not close. The questions worth asking an outside partner are on our guide to medical billing companies, and the work itself is set out under full-service medical billing. A free billing review runs your own monthly ESRD claims against the census.

Pediatric nephrology

This is where the age band is a live monthly decision rather than a field that never changes. Three of the four bands sit under 20, so patients cross a boundary at 2, at 12 and at 20, and the code moves the month the birthday falls rather than the month after. The dollars are the largest in the set: 90951 allows $1,183.73 and 90954 allows $1,034.43 in 2026, and 90952 and 90953 are contractor priced rather than national. Our pediatric billing page covers the wider age-driven code families.

Adult nephrology and dialysis groups

Age is effectively fixed here, so the monthly decision collapses onto setting and visit count. That makes the tier boundary between 90960 and 90961 the most valuable number in the practice, at $62.12 a patient month, and makes the home-versus-in-center flag the thing to get right before anyone counts anything. The transitioning 19-year-old inherited from a pediatric program is the one age case that still bites. The claim side is covered on our nephrology billing page.

Home dialysis programs

The code is chosen by age alone, which produces its own failure mode: nobody documents the monthly visit because no tier depends on it. The assessment still has to be there, with the in-person access examination, and a month carrying no documented face-to-face contact will not survive review even though the code was right. The other recurring case is the patient who spends part of the month in a unit and is still correctly billed 90963 to 90966. Training is billed apart from these codes, as our guide to billing home dialysis training with 90989 explains.

Hospital-based nephrology

The boundary that matters is which visits count. Observation and skilled nursing facility visits count toward the tier; inpatient visits do not, and are billed on their own codes. Where a patient is admitted mid-month, the complete assessment decides whether the month stays a monthly code or becomes per-day units, and 42 CFR 414.314(b)(3) reduces the monthly amount for hospital days the physician bills separately. Our walkthrough of mid-month admissions for dialysis patients takes that decision step by step.

Primary care and internal medicine

Internists covering a dialysis unit rarely bill these codes often enough to build a habit, which is the risk. Two rules catch most of the trouble: one monthly payment exists per patient per month, so a code billed alongside the nephrology group’s is recovered in full, and the physician who bills is the one who furnishes the complete assessment and sets the plan of care. Where a nurse practitioner does that, the claim goes under their own provider number.