How is home dialysis training billed separately from the MCP?

The question carries its own error. Nearly every page that answers it says training is excluded from the monthly capitation payment, and that framing is exactly where the money goes. Training was never inside the MCP to be carved out of it. It is paid under a different regulation, by a different method, and on the facility side by a different payment system altogether.

Is home dialysis training part of the MCP, or a separate payment?

Separate, and the regulation settles it in one sentence. 42 CFR 414.316 governs payment for physician services to patients in training for self-dialysis and home dialysis. The carrier pays a flat amount per patient that covers all physician services required to create the capacity for self-dialysis. The payment is made at the end of the training course, it is subject to the deductible and coinsurance, and it is in addition to any amounts payable under the initial or MCP methods set out in 414.313 and 414.314.

Now read the MCP regulation itself. 42 CFR 414.314(b)(1) lists the five categories of service excluded from the monthly capitation payment and payable under the reasonable charge rules: hepatitis B vaccine administration, services by another physician when the attending physician is unavailable, services to hospital inpatients where the physician elects not to continue receiving the MCP, surgical services including shunt declotting, and needed services unrelated to the renal condition. Training is not on that list. It never needed to be.

The payer pages that file training under MCP exclusions describe the outcome rather than the mechanism. Noridian lists training patients to perform home or self hemodialysis and various forms of self peritoneal dialysis beneath its MCP exclusions heading, which is operationally right and conceptually misleading. The distinction shows up at the claim: an excluded service normally needs a modifier, a distinct diagnosis or a narrative to survive a bundling edit, and a payment made under its own regulation needs none of those things.

When do you bill 90989, and when do you bill 90993?

90989 reports a completed course of dialysis training for the patient, including a helper where one is involved. 90993 reports the same training when the course is not completed, priced per training session. One code closes a course; the other prices the fragment.

The logic behind the split sits in the same regulation. 414.316(d) states that if the training is not completed, the payment amount is proportionate to the time spent in training. The flat amount buys a finished capability, and a course that stops short pays a share of it. That is also why the date of service on a 90989 line is the day the course completes rather than the day it started: the regulation makes completion the trigger for payment.

Where the per-session reading goes wrong

Coding forums treat 90993 as a running per-session code billed alongside 90989 as the course progresses. It is not. A course that finishes is one unit of 90989 and nothing else; a course abandoned because the patient returns to in-center dialysis or is transplanted mid-course becomes 90993 for the sessions delivered. Billing both for one course is a duplicate, and duplicate claim denials made up 9% of denials in our claim audit, mostly from resubmitting instead of correcting.

Can 90989 and the ESRD monthly capitation payment share a month?

Yes, with nothing else required. The training payment is additive by the plain text of 414.316(c), so the monthly capitation code for that month is billed at its ordinary value and the training line sits beside it.

What does reduce the MCP is unrelated. 414.314(b)(3) cuts the monthly payment in proportion to the days a patient is hospitalized where the physician elects to bill separately for that period, and to the days the patient is not attended by the physician or a substitute. Training is neither. A nephrologist who manages a home patient for a full month and completes the training course inside that month bills the full-month code and the training code, not a reduced one.

Which monthly code the home patient carries

Home patients run on 90963 to 90966 by age, with 90966 covering a full month for a patient 20 or older at a 2026 Medicare national amount of $310.29. Per-day codes 90967 to 90970 cover partial months, transient patients and a permanent change of monthly physician. Picking between them is the same exercise described on our nephrology billing page and is unaffected by whether training happened. Monthly dialysis visit counts were miscoded on 8% of capitated claims in our audit, and a training month is a common place for that error, because the schedule looks nothing like a normal month.

What does Medicare actually pay for 90989 and 90993?

This is where the lookup fails. Both codes carry zero work, practice expense and malpractice relative value units on the Medicare physician fee schedule, so a rate database returns no national amount and often labels them not covered. Coders read that and conclude the service is unpayable.

The fee schedule is simply not where the amount lives. 414.316 says the carrier pays a flat amount that CMS determines and reviews periodically, which puts the number with the Medicare administrative contractor rather than in the national file. The figure in circulation, cited by MAC guidance to Chapter 8 section 150 of the Medicare Claims Processing Manual, is a flat $500 for a completed course, with incomplete courses priced per session at roughly $20. Confirm your own MAC amount before you model anything on it, because a carrier-priced code is exactly the kind that varies.

Set the three Medicare streams attached to one home start side by side and the physician fee is the smallest of them. The facility training add-on across a full 25-session hemodialysis course is worth $2,390, the physician course fee is $500, and the home monthly capitation payment for that month is $310.29.

The practical consequence is that the party with the most to lose from a mishandled training course is usually the facility, not the nephrologist, and the two claims are prepared by different people who rarely compare notes.

How does the facility training add-on work, and who gets it?

The facility bills its training treatments on the ESRD prospective payment system claim and receives a training add-on payment adjustment on top of the base rate for each training treatment. The add-on is built from the national average hourly wage for nurses and adjusted by the ESRD wage index, so it moves with geography.

Three mechanics decide whether it pays. Condition code 73, self-care in training, identifies the training treatment on the claim; condition code 87 identifies self-care retraining and has to fall inside the training certificate dates. The treatments are reported under the revenue code range for the modality, 082X for hemodialysis, 083X for peritoneal, 084X for CAPD and 085X for CCPD. And the session count is capped: Chapter 8 section 50.8 allows a maximum of 25 training sessions per patient for hemodialysis training, 15 for CAPD and 15 for CCPD, with intermittent peritoneal dialysis limited to three treatments a week across three months.

The amount itself has moved a long way and most published guidance has not kept pace. Chapter 8 still prints a training add-on of $33.44. The current CY2026 figure is $95.60, and CMS has proposed $138.22 for CY2027 alongside a base rate rising from $281.71 to $299.55.

The onset trap that zeroes the add-on

Here is the part no ranking page explains. Under current policy the ESRD PPS does not pay the training add-on during the onset of dialysis adjustment period, the first four months of ESRD dialysis. That window is precisely when most home training happens. A facility that trains a new patient promptly, which is the clinically correct thing to do, collects no add-on at all for those sessions today.

CMS proposed to change this in the CY2027 ESRD PPS proposed rule published on 24 June 2026, allowing the add-on during the onset period on a budget neutral basis. Until that is final, the add-on is a real line item for retraining and for later modality switches, and a zero for the ordinary new start. Build the expectation into the budget rather than discovering it on the remittance, and keep the sessions coded correctly regardless, because the claim history is what supports payment once the rule changes.

Why starting training before the fourth month changes the whole claim

ESRD Medicare normally begins on the first day of the fourth month of dialysis. It begins in the first month instead when the patient enters a home dialysis training program during those first three months. Three months of coverage that would otherwise be the patient or a commercial plan move to Medicare, and three months of monthly capitation payments become billable that were not before.

That single fact outweighs the training codes themselves, and it runs through eligibility rather than coding. It also collides with the 30-month coordination period, since a patient with employer group health coverage still has the group plan paying first for 30 months regardless of when entitlement starts. Getting that order right before the first claim goes out is eligibility and benefit verification work.

Take a six-nephrologist group with an affiliated home program and 24 home starts a year. Billed correctly, the physician training fee alone is 24 courses at $500, or $12,000 a year. In our nephrology audit no 90989 or 90993 reached any claim for 31% of patients who started a home modality, which here is 7.4 starts and $3,720 of physician revenue a year that no denial ever reports. On the facility side the same 24 courses represent 25 sessions each at the current $95.60, or $57,360, none of which is payable today when training falls inside the onset window. At the proposed $138.22 the same courses would carry $82,932. Run the arithmetic against your own start volume and wage index rather than these figures.

Where home dialysis training claims actually fail

Most of the loss is not a denial. A service that is never billed produces no remittance, no denial code and no line on a denial report, which is why it survives year after year while the team works the claims that did come back.

Across the home dialysis training failures we see, training never billed at all accounts for 36%, a missing condition code 73 for 24%, sessions billed past the modality cap for 22%, and retraining coded without condition code 87 for 18%. Only the last three ever reach a remittance.

Work them in that order. Start by counting home starts in the period and asking how many carry a 90989 or a 90993, because that number is usually the largest and nobody is looking at it. Then check condition codes on the facility claims. Then reconcile session counts against the caps before submission rather than after, since a capped session is a correction and not an appeal. Appeals we file are overturned 68% of the time, but 19% of denied claims are never reworked or appealed at all, and a training claim is the kind that quietly joins that group. Sorting these into corrected claims, appeals and write-offs before anyone touches them is what a denials and AR recovery queue exists for, and keeping the two claims aligned in the first place is coding work done before submission.

Should this sit in house or with a billing partner?

Keep it in house when one named person owns the home program end to end: training certificate dates, session counts against the modality caps, condition codes on the facility claim and the 90989 on the physician claim. This is a knowledge problem rather than a volume problem, and 24 courses a year is not a workload.

Move it outside when nobody does that job, or when the professional and facility claims are prepared by teams that never speak. Fully loaded in-house billing cost 7.9% of collections for practices under $2M in our reviews, against an outsourced range of 3% to 6% of collections. That gap only matters if the outside team reports on what was never billed rather than only on what came back denied, which is the question worth asking: our page on choosing a medical billing company covers the rest, and full-service medical billing describes a complete engagement inside your existing system. Either way, start by pulling twelve months of home starts and counting how many produced a training line. A billing review runs that against your own records.

Physician claim or facility claim: which one carries the training payment?

Both do, for different work, under different rules, to different payers. The table below is the split that no page in the current search results puts in one place.

The line to hold on to: the nephrologist is paid for creating the capability, the facility is paid for the nursing hours that deliver it, and neither payment touches the MCP. Where the two claims disagree about how many sessions happened or when the course closed, the facility claim is usually the one that gets reviewed. The wider front-end picture sits in nephrology revenue cycle management.

Nephrology

This is the claim that gets forgotten, because the physician training fee is small next to a month of capitation and it arrives once per patient rather than every month. Build it into the home start workflow instead of the charge sheet: when the home program opens a training certificate, a task should open on the physician side that closes with a 90989 on the completion date. The same visit discipline that governs the monthly codes applies here. Monthly dialysis visit counts were miscoded on 8% of capitated claims in our audit, and the training month is where that starts. Our breakdown of monthly ESRD code tiers by age and visits shows how those monthly codes are set.

Dialysis facilities and home training programs

The facility carries the larger number and the tighter rules. Condition code 73 on every training treatment, condition code 87 for retraining inside the certificate dates, revenue code matched to modality, and session counts held under 25 for hemodialysis and 15 for CAPD or CCPD. Because the add-on is not payable during the onset period today, a facility budgeting home growth on add-on revenue will miss. Code the sessions correctly anyway, since the CY2027 proposal would turn that same claim history into payment.

Hospital-based and critical access dialysis

Hospital-based units run the professional and facility claims through different departments and different systems, which is the structural reason the two sides disagree about session counts. Reconcile the training log against both claims before either is submitted. Critical access hospitals paid on reasonable cost rather than the ESRD PPS sit outside the add-on mechanics entirely, so applying a generic ESRD checklist produces wrong expectations. Our hospital billing work starts by establishing which payment system each line belongs to.

Primary care and internal medicine

Primary care rarely bills any of this and still decides part of it. The physician who refers a late-stage CKD patient into a home training program before the fourth month of dialysis is the reason Medicare entitlement can start in month one rather than month four. Kidney disease education under G0420 and G0421 is a separate benefit limited to stage 4 CKD with a lifetime limit of six sessions, and it is not dialysis training. Mixing the two is a common and avoidable denial.

Home health

Home health agencies supporting a home dialysis patient are not paid for dialysis-related services in the home under most state and Medicare rules, and training is not a home health service. Where an agency is involved for an unrelated plan of care, keep the dialysis-related visits off the home health claim entirely. The boundary questions are the same ones covered on our home health billing page.