90963
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
12.09
Facility
$626.27
Non-Facility
$626.27
Documentation Required
- Diagnosis documentation: medical record documenting diagnosis of end-stage renal disease (ESRD) and indication for renal replacement therapy.
- Clinical stability: documentation that the individual is 'stable on dialysis' (clinical notes, dialysis session records) and notation that no skilled care interventions are required during routine treatments for coverage without skilled care.
- Training records: evidence of comprehensive training completion for the patient and/or non-professional caregiver (e.g., completed course CPT 90989 or per-session 90993 where applicable), including competency assessment.
- Caregiver capability: documentation that a non-professional caregiver is available, trained, and able to assist (if applicable) or documentation that patient/caregiver is not capable (for skilled care pathway).
Key Coverage Criteria
- Home hemodialysis (HHD) as an alternative to facility-based hemodialysis for individuals with end-stage renal disease (ESRD) who meet ALL of the following (HHD without skilled care): individual is stable on dialysis with no evidence of skilled care interventions being necessary during treatments; and the individual undergoing hemodialysis or a non-professional caregiver has the ability to perform and maintain home hemodialysis and has received comprehensive training regarding proper protocol; an [...]
- Home hemodialysis WITH skilled care as an alternative to facility-based hemodialysis for individuals with ESRD who meet ALL of the following: individual is stable on dialysis and not at increased risk as a result of having the procedure performed outside a dialysis center venue; and the individual undergoing hemodialysis or non-professional caregiver is NOT capable of performing home hemodialysis; and the individual has medical contraindications to leaving home for hemodialysis; and individual h [...]
- HHD for pediatric patients as applicable under ESRD-related services codes (CPT 90963–90969) when the patient meets the general coverage rationale and age-specific CPT definitions apply (codes listed in policy for reference).
- Services and per-diem administrative/care coordination/supplies for home hemodialysis (HCPCS S9335) when provided as described and when member meets coverage criteria and benefit plan provisions (codes listed in policy for reference).
- Medical nutrition therapy/nutritional counseling for chronic disease states: kidney disease.
- Nutritional counseling as a medically necessary preventive service for children who are obese.
4 Active Policies
UHC-POL-home-hemodialysis — Home Hemodialysis
UMR-POL-UMR-home-hemodialysis — Home Hemodialysis
SUREST-POL-SUREST-home-hemodialysis — Home Hemodialysis
AETNA-CPB-0049 — Nutritional Counseling
Related Codes
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