Nephrology Billing Services

Nephrology billing does not work like the rest of medicine. Dialysis patients are not billed per encounter, they are billed through a single monthly capitation payment, and mixing that model with ordinary visit billing is the fastest way to generate overpayment recoveries. Add chronic kidney disease staging, vascular access procedures, and transplant coordination, and nephrology claims need a billing team that understands two payment models at once.
MedPlus RCM provides medical billing, coding, credentialing, and denial management for nephrology practices, built around dialysis capitation, CKD management, and vascular access coding.

Nephrology billing challenges

The monthly capitation payment, or MCP, is the core challenge. For patients on maintenance dialysis, Medicare pays a single monthly code per patient, and the code tier depends on the patient’s age group and the number of documented face-to-face visits in the calendar month: one visit, two to three visits, or four or more visits, with the highest tier at four or more. Billing only one MCP code per patient per month is a hard rule, and a second code for the same month is recovered as an overpayment. Session-based dialysis codes for physician evaluation during a dialysis session are a separate model, and billing session codes alongside MCP for routine supervision is a bundling violation. Session codes belong to distinct evaluations, such as acute complications during the session, not to routine monthly management.
Chronic kidney disease staging is the second challenge. Pre-dialysis CKD care is billed with standard evaluation and management codes, but the diagnosis must carry the stage-specific code, since payers frequently deny claims when the CKD stage is not specified. Vascular access work adds its own bundling and global period logic, separate from the dialysis codes, and access procedures need laterality and modifier accuracy, particularly when an evaluation and management service is billed on the same day as an access procedure.
Coordination of benefits is the third challenge. Many dialysis patients carry commercial coverage alongside Medicare, and for end-stage renal disease, Medicare typically becomes the primary payer after a 30-month coordination period when the patient has group health plan coverage. During that period the commercial plan is usually primary. Billing the wrong payer first, or failing to sequence the primary payment before the secondary claim, delays the entire month’s revenue.

What MedPlus RCM handles for nephrology practices

• End-to-end medical billing. Charge entry, claim scrubbing, submission, payment posting, and patient billing, the full cycle.
• Medical coding. Certified coders assign current ICD-10, CPT, and HCPCS codes matched to your documentation and specialty.
• Provider credentialing and enrollment. End-to-end enrollment with commercial payers, Medicare, and Medicaid, plus re-credentialing maintenance.
• Denial management and recovery. Every denial investigated to root cause, corrected, and appealed with documentation.
• A/R recovery. Aged and outstanding balances audited and pursued, including balances already written off where the appeal window is still open.
• Financial reporting. Clean claim rates, collections, denial patterns, and A/R aging visible by payer and provider.

We serve nephrology practices of every size, from solo nephrologists to multi-provider groups, across all 50 states.

Results nephrology practices can check

MedPlus RCM maintains a 99% clean claim rate and keeps client accounts receivable under 30 days. Pricing is a performance-based percentage of successfully collected revenue: if you don’t get paid, we don’t get paid. We are 100% HIPAA compliant, and onboarding takes 2 to 4 weeks depending on practice size, with no disruption to your daily cash flow.

Frequently asked questions

How does the monthly capitation payment work?
One code per dialysis patient per month, with the tier set by age group and the number of documented face-to-face visits that month: one visit, two to three visits, or four or more visits. Only one MCP code may be billed per patient per month.
Can session dialysis codes be billed with the monthly capitation payment?
No, not for routine supervision. Session codes cover a distinct physician evaluation during a dialysis session, such as an acute complication, and billing them alongside MCP for routine management is a bundling violation.
Why do CKD claims deny for diagnosis reasons?
Usually because the CKD stage was not specified. Stage-specific diagnosis codes must match the documented stage and kidney function, and an unspecified kidney disease code frequently fails medical necessity edits.
Who pays first for a dialysis patient with commercial insurance?
During the 30-month coordination period for end-stage renal disease, the group health plan is usually primary and Medicare is secondary. After that period, Medicare typically becomes primary. Claims must be sequenced accordingly.
How long does it take to switch our billing to MedPlus RCM?
Onboarding takes between 2 and 4 weeks depending on practice size, including data migration and payer clearinghouse setup.
What does MedPlus RCM charge?
A performance-based percentage of successfully collected revenue. If you don’t get paid, we don’t get paid.

Get a free financial audit

Find out where your nephrology practice is losing revenue. Request a free financial audit and our specialists will review your claims, denials, and A/R.
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