ESRD monthly reconciliation
Match documented face-to-face visits per patient per month to the correct capitation tier before the claim goes out.
Nephrology | Texas
Nephrology billing built around dialysis rounds, not a generic claim queue.
Nephrology revenue turns on monthly ESRD capitation, visit counts that must be documented before they can be billed, and rounding that happens away from the office. T Zync bills nephrology the way it is practiced.
Designed for
Independent nephrology practices and dialysis-rounding physicians in Texas
No PHI through public forms
01 Why nephrology is different
The month is the billing unit, and the visit count decides the code.
Nephrology is one of the few specialties where a month of care is billed as a single service. The ESRD monthly capitation codes are selected by patient age and by how many face-to-face visits actually occurred and were documented during that month, which means the billing is only as good as the rounding record.
Two failure points cost Texas nephrology practices the most. The first is billing a higher-tier monthly code than the documented visits support, which turns into a refund on review. The second is billing a full month when the patient was hospitalized, transplanted or transient, where per-day codes apply instead.
T Zync reconciles the dialysis rounding log against the claim before submission, so the code billed matches the visits documented, every month, for every unit the practice covers.
02 What we handle
The full nephrology revenue cycle.
Multi-unit rounding capture
Track visits across every dialysis facility the practice covers, so no month is billed from an incomplete log.
Partial-month handling
Apply per-day ESRD services correctly for hospitalizations, transplants, transient patients and mid-month starts.
Home dialysis billing
Bill home and self-care dialysis management under the correct monthly structure.
CKD office visits
Code office-based CKD care with correct staging specificity and longitudinal-care add-on where supported.
Vascular access procedures
Bill dialysis circuit diagnostic and interventional work with attention to bundling edits.
Anemia and injectable management
Handle in-office injectable claims with the reporting payers require, including drug units and wastage.
A/R and denial recovery
Work aged nephrology balances with attention to Texas filing limits before they close.
03 Codes that carry nephrology revenue
The code families this work lives in.
Nephrology billing concentrates into a small number of high-value code families. Getting these right is most of the job.
| Code family | What it covers |
|---|---|
| 90951–90962 | Monthly ESRD services for outpatient dialysis patients, selected by patient age and by the number of documented face-to-face visits in the month. |
| 90963–90966 | Monthly ESRD services for home dialysis patients, selected by patient age. |
| 90967–90970 | Per-day ESRD services used when a full month does not apply, such as hospitalization, transplant, a transient patient or a partial month of care. |
| 90935, 90937 | Hemodialysis procedures with a single evaluation, or with repeated evaluations during the session. |
| 90945, 90947 | Dialysis procedures other than hemodialysis, including peritoneal dialysis, with single or repeated evaluation. |
| 36901–36909 | Diagnostic and interventional procedures on the dialysis circuit, where bundling edits decide what is separately payable. |
| G0420, G0421 | Medicare kidney disease education services, individual and group, for qualifying patients with stage IV chronic kidney disease. |
| 99490, 99439 | Chronic care management for CKD patients carrying multiple chronic conditions, where the time and care-plan requirements are documented. |
| N18.1–N18.6, Z99.2 | CKD staging specificity and dialysis dependence, which payers rely on to support the service billed. |
Codes listed reflect common documentation scenarios in this specialty and are shown for orientation. Correct code selection always depends on the documentation, the payer's policy and the current code set for the year of service. T Zync verifies current payer policy at the time of billing.
04 How it runs
A monthly rhythm that matches dialysis care.
- 01
Reconcile
Compare the rounding log to the month's documented visits, per patient and per unit.
- 02
Code
Select the monthly, per-day or procedure code the documentation actually supports.
- 03
Submit and monitor
File against Texas payer rules and track the month to payment, not just to acceptance.
- 04
Recover and prevent
Work denials against filing deadlines and push recurring causes back into the rounding record.
05 Texas payer landscape
The payers and deadlines that decide a Texas claim.
Texas nephrology practices bill the same patient every month, so a filing lapse repeats across a whole panel before anyone notices. These are the rules that decide whether a balance is still recoverable.
| Payer or rule | What it means for your claims |
|---|---|
| Medicare – Novitas Solutions (Jurisdiction H) | The Part B contractor for Texas. Claims carry a twelve-month timely filing limit from the date of service, and a redetermination must be requested within 120 days of the initial determination notice. |
| Texas Medicaid (TMHP) | Fee-for-service claims must be filed within 95 days of the date of service, one of the shortest limits in the country and a frequent cause of unrecoverable Texas denials. |
| Medicaid managed care (STAR, STAR+PLUS) | Each managed care plan applies its own filing, authorization and appeal rules on top of state policy, so payer-specific edits matter more than a single Medicaid workflow. |
| Texas prompt pay | State-regulated HMO and PPO plans carry statutory deadlines for paying clean claims, which gives a documented clean submission real leverage in follow-up. |
| Commercial and Medicare Advantage | Filing limits are contract-specific and commonly range from 90 to 180 days, so the follow-up calendar should be driven by the contract rather than by habit. |
| ESRD monthly claims and filing windows | Because monthly capitation is billed once per patient per month, a delay in closing the month pushes an entire panel of claims toward the filing limit at the same time, not one claim at a time. |
Filing limits and appeal windows are set by payer policy and by contract, and they change. T Zync verifies the applicable deadline per payer at the time of work.
FAQ Nephrology billing guidance
Nephrology billing questions, answered clearly.
For guidance specific to your specialty, payer mix and systems, speak with T Zync.
How is the monthly ESRD code selected?
By the patient's age and by the number of documented face-to-face visits with the physician or qualified practitioner during the calendar month. The documentation has to support the visit count before the corresponding tier can be billed.
What happens when a dialysis patient is hospitalized mid-month?
The full monthly capitation code may no longer be appropriate for that month. Per-day ESRD services are used for the applicable days instead, which is one of the most common sources of nephrology refund requests when handled incorrectly.
What is the timely filing limit for Texas Medicaid?
Texas Medicaid fee-for-service claims must be filed within 95 days of the date of service. Managed care plans apply their own limits, so aged nephrology A/R in Texas needs to be triaged against the specific payer rather than a single rule.
Can you bill across multiple dialysis units?
Yes. Visits are tracked per facility and reconciled into a single monthly view per patient, which is what prevents a month being billed from an incomplete rounding log.
Do you handle CKD office visits as well as dialysis?
Yes. Office-based CKD care, staging specificity and longitudinal-care add-on codes are billed alongside the dialysis work, since most nephrology practices carry both.
Which Medicare contractor processes Texas nephrology claims?
Novitas Solutions administers Medicare Part B for Texas under Jurisdiction H, and its local coverage policies apply to nephrology services billed in the state.
06 Keep exploring
Related services and specialties.
Recover and prevent
Denial Management
Root-cause appeals and prevention rules built around your payer mix.
Before the service
Prior Authorization
Approvals secured before the visit, with reauthorization tracking.
Nearby specialty
Rheumatology Billing in Texas
Infusion coding, biologic J-codes and buy-and-bill protection.
Start with clarity