What CPT codes are used for dialysis monthly visits?

ESRD-related services use MCP codes based on monthly face-to-face visits: 90960 (4+ visits/month for patients ≤2 years old), 90961 (2-3 visits/month), 90962 (1 visit/month), 90963-90966 for home dialysis, and 90970 for patients requiring less than full month of services. These codes cover all ESRD-related E/M services, dialysis prescription management, and care coordination for the month.

What dialysis adequacy documentation is required?

Document Kt/V (goal ≥1.4 for HD, ≥1.7 weekly for PD), URR (≥70% for HD), treatment time, blood flow rate, and dialysate composition. For inadequate clearance, document cause (access problems, shortened treatments, missed sessions) and corrective actions. Monthly labs should include BUN pre/post, potassium, calcium, phosphorus, and albumin. Quarterly PTH and annual hepatitis serologies are also required.

How should vascular access assessment be documented?

Document access type and location, physical exam findings (thrill, bruit, aneurysms, steal symptoms, infection signs), recent interventions (fistulogram, angioplasty, thrombectomy), cannulation issues, and flow alarms. For catheters, document exit site appearance, tunnel, and any dysfunction. Access surveillance should be performed monthly and documented with findings and plan for any issues.

What CKD-MBD management documentation is needed?

Document calcium, phosphorus, PTH levels with goals (PTH 150-600 pg/mL for HD, 150-300 for PD; Ca×P product <55), vitamin D level, and alkaline phosphatase. Include current phosphate binder regimen (type, dose, timing with meals), vitamin D analog (type, dose), and calcimimetic if used. Document dietary phosphorus counseling and medication adherence assessment.

How do I document anemia management in dialysis patients?

Document hemoglobin (goal 10-11 g/dL), iron indices (ferritin >200, TSAT >20%), ESA drug/dose/route/frequency, and response to therapy. For EPO-resistant anemia, document evaluation for causes (iron deficiency, infection, malignancy, hyperparathyroidism). Track ESA dose adjustments and document rationale for holding (Hgb >11, uncontrolled hypertension) or increasing doses.

Dialysis Follow-up Template - Nephrology

Visit Information

Date: [Date]
Visit type: Monthly dialysis visit / Interim visit
Dialysis modality: Hemodialysis / Peritoneal dialysis

Patient Information

ESRD etiology: [Diabetes / HTN / GN / PKD / Other]
Dialysis start date: [Date]
Dialysis vintage: [X] months/years
Transplant status: Not listed / Listed — [Date, status]

Current Dialysis Prescription

Hemodialysis

Schedule: [X] times/week
Duration: [X] hours/session
Access: Fistula / Graft / Catheter — Location: [X]
Dialyzer: [Type, size]
Blood flow: [X] mL/min
Dialysate flow: [X] mL/min
Dialysate: [K, Ca, bicarb]
Dry weight: [X] kg
UFR goal: [X] mL/hr

Peritoneal Dialysis

Type: CAPD / APD / Hybrid
Exchanges: [Number, volume, dwell times]
Dialysate: [Dextrose concentration, icodextrin]
Cycler settings (if APD): [Program details]
Total daily UF goal: [X] mL

Interval History

Dialysis Sessions

Attendance: All sessions / Missed [X] sessions — Reason: [X]
Session tolerance: Good / Fair / Poor
HD complications this month:

Hypotension: None / [X] episodes
Cramping: None / [X] episodes
Access issues: None / [Description]
Clotting: None / [Episodes]
Bleeding: None / [Episodes]

PD complications this month:

Peritonitis: No / Yes — [Date, organism]
Exit site infection: No / Yes
Drain problems: None / [Description]
Leakage: None / [Description]

Volume Status

Current symptoms:

Edema: None / [Grade, location]
Dyspnea: None / [Severity]
Orthopnea: None / [Pillow number]
Weight gain between sessions: [X] kg average

Fluid intake: [Compliance with restriction]
Sodium intake: [Compliance]
Inter-dialytic weight gain (HD): [X] kg average
UF achieved per session: [X] L average
Post-HD BP: [X/X] average

Uremic Symptoms

Appetite: Good / Fair / Poor
Nausea/vomiting: None / [Frequency]
Pruritus: None / Mild / Moderate / Severe
Fatigue: None / Mild / Moderate / Severe
Sleep: Good / Fair / Poor
Restless legs: None / Present
Cognitive: Normal / [Concerns]

Access Function (HD)

Needle placement: Easy / Difficult
Buttonhole: No / Yes
Problems: None / [Difficult cannulation, prolonged bleeding, infiltration]
Flow alarms: None / [Frequency]
Thrill/bruit: Normal / [Changes]
Recent intervention: None / [Fistulogram, angioplasty — date]

PD Access

Exit site: Clean / [Erythema, drainage, granulation]
Tunnel: Non-tender / [Tenderness]
Cuff: Not palpable / Palpable / Extruding
Last exit site care: [Technique, frequency]

Current Medications

EPO/ESA: [Drug, dose, route, frequency]
Iron: [Drug, dose, route, frequency]
Phosphate binders: [Drug, dose, with meals]
Vitamin D analog: [Drug, dose]
Calcimimetic: [Drug, dose]
Antihypertensives: [List]
Other: [List]
Medication changes needed: None / [Specify]

Physical Examination

Vital Signs

Pre-dialysis BP: [X/X]
Post-dialysis BP: [X/X]
HR: [X]
Temp: [X]°F
Weight: [X] kg — Dry weight: [X] kg — Difference: [X] kg

General

Appearance: Well / [Uremic, volume overloaded]
Nutritional status: Adequate / [Concerns]

Cardiovascular

JVD: Absent / [X] cm
Heart sounds: Normal / [S3, rub]
Edema: None / [Grade, distribution]

Pulmonary

Breath sounds: Clear / [Crackles — location]

Abdomen

PD catheter exit site (if PD): Clean / [Findings]
Peritonitis signs (if PD): Absent / [Tenderness, guarding]

Access Examination (HD)

Type: Fistula / Graft / Catheter
Location: [Anatomic site]
Thrill: Strong / Weak / Absent
Bruit: Present / Diminished / Absent
Aneurysm: None / [Location, size]
Steal: Absent / [Symptoms]
Edema (arm): None / Present
Infection signs: None / [Erythema, warmth, drainage]
Catheter (if applicable):

Site: Clean / [Erythema, drainage]
Tunneled: Yes / No
Cuff: [Status]
Locking solution: [Heparin, citrate]

Laboratory Review

Dialysis Adequacy

HD:

spKt/V: [X] — Goal: ≥1.4
URR: [X]% — Goal: ≥70%

PD:

Weekly Kt/V: [X] — Goal: ≥1.7
Weekly creatinine clearance: [X] L/week

Chemistry

Lab	Value	Goal	Status
BUN pre	[X]
BUN post	[X]
Creatinine	[X]
Potassium	[X]	3.5-5.5	[OK/High/Low]
Bicarbonate	[X]	22-26	[OK/Low]
Calcium	[X]	8.4-9.5	[OK/High/Low]
Phosphorus	[X]	3.5-5.5	[OK/High/Low]
Albumin	[X]	>4.0	[OK/Low]

CKD-MBD

PTH: [X] pg/mL — Goal: 150-600 (HD), 150-300 (PD)
Vitamin D 25-OH: [X] ng/mL
Alkaline phosphatase: [X]
Ca x P product: [X] — Goal: <55

Anemia

Hemoglobin: [X] g/dL — Goal: 10-11
Hematocrit: [X]%
Ferritin: [X] ng/mL — Goal: >200
TSAT: [X]% — Goal: >20%
Reticulocyte count: [X] (if EPO resistance)

Other

Glucose: [X]
A1c: [X]% (if diabetic)
Hepatitis B surface Ab: [X] — Vaccine status: [X]
Hepatitis C: [Last check, status]

Assessment

1) ESRD on [HD/PD]

Adequacy: Adequate / Inadequate — Kt/V: [X]
Access: Functioning well / [Issues]
Volume status: Euvolemic / [Overloaded/dry]

2) CKD-MBD

PTH: [Controlled/elevated/suppressed]
Phosphorus: [Controlled/elevated]
Calcium: [Normal/abnormal]

3) Anemia of CKD

Hgb: [X] — [At goal/below goal]
Iron status: [Replete/deficient]

4) [Other issues — HTN, DM, nutrition, etc.]

Plan

Dialysis Prescription

[ ] Continue current prescription
[ ] Modify prescription:

[ ] Increase time to [X] hours
[ ] Increase frequency to [X]/week
[ ] Change dialyzer to [Type]
[ ] Adjust dialysate: [K, Ca, bicarb]
[ ] Change dry weight to [X] kg

Access Management

[ ] Access functioning well — Continue current care
[ ] Refer for fistulogram
[ ] Refer for access revision
[ ] Schedule catheter removal (if maturing access)
[ ] Catheter exchange needed
[ ] Exit site care education (PD)

CKD-MBD Management

Phosphate binders:
[ ] Continue current
[ ] Add/increase: [Drug, dose]
[ ] Change to: [Drug, dose]
Vitamin D:
[ ] Continue current
[ ] Start/increase: [Drug, dose]
[ ] Hold — Reason: [X]
Calcimimetic:
[ ] Not indicated
[ ] Continue current
[ ] Start/adjust: [Drug, dose]

Anemia Management

ESA:
[ ] Continue current: [Drug, dose, frequency]
[ ] Increase dose to: [X]
[ ] Decrease dose to: [X]
[ ] Hold — Reason: [Hgb >11, hypertension]
Iron:
[ ] Iron replete — Continue maintenance
[ ] Iron deficient — Give IV iron: [Drug, dose, schedule]
[ ] Start oral iron: [Drug, dose]

Volume/Blood Pressure

[ ] At dry weight — Continue current
[ ] Reduce dry weight to [X] kg
[ ] Increase dry weight to [X] kg
[ ] Optimize antihypertensives: [Changes]
[ ] Dietary counseling: Sodium/fluid restriction

Other Medications

[ ] No changes
[ ] [Medication changes]

Monitoring

Labs for next month: [ ] Monthly panel [ ] PTH (quarterly) [ ] Other: [X]
Access surveillance: [ ] Routine [ ] Fistulogram scheduled

Referrals

[ ] Vascular surgery
[ ] Transplant (if not listed)
[ ] Dietitian
[ ] Social work
[ ] Vascular access center

Patient Education

Dialysis adequacy reviewed
Fluid/sodium restriction
Phosphorus diet
Medication changes
Access care

Follow-up

Return: [X] weeks (monthly required)

Labs: [X] days before visit

Interim: PRN for access issues, volume problems, infections

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