CPT Codes 90945 & 90947: Complete Peritoneal Dialysis Billing Guide, Documentation, Reimbursement & Coding Guidelines (2026)

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Peritoneal dialysis billing is a specialized corner of nephrology revenue cycle management where documentation gaps and code selection errors have an outsized financial impact. CPT codes 90945 and 90947 the two core per-session dialysis codes for peritoneal dialysis, hemofiltration, and other non-hemodialysis renal replacement therapies are among the most frequently miscoded dialysis codes in the country, and that misuse creates denial patterns that compound month over month across a busy dialysis billing operation.

Part of the challenge is structural. Many billing teams treat 90945 and 90947 as interchangeable choosing one or the other based on habit, payer behavior, or the assumption that the physician's involvement level is implied by the diagnosis. It is not. The selection between these two codes is driven entirely by what the physician documented doing during the dialysis session itself: one evaluation or multiple evaluations with active patient management. Getting that distinction right every time requires a documentation-first billing culture that most in-house teams are not resourced to maintain consistently.

At MedCloudMD, our nephrology billing specialists work directly with dialysis centers, nephrologists, and hospital billing departments to build compliant, revenue-optimized workflows for these codes. This 2026 guide covers everything your team needs to know from code definitions and clinical triggers to denial prevention checklists and audit-ready documentation standards.

💡  Did You Know?

CPT 90945 and 90947 apply to peritoneal dialysis, hemofiltration, continuous renal replacement therapy (CRRT), and other non-hemodialysis dialysis modalities. They are per-session codes not monthly capitation codes. Billing a monthly home PD code (90963-90966) when an acute per-session code applies, or vice versa, is one of the most costly and most preventable code family errors in dialysis billing.

01 — Quick Code Overview: CPT 90945 & 90947

02 — What Is CPT Code 90945?

CPT 90945 is defined as: Dialysis procedure other than hemodialysis (e.g., peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies), with single evaluation by a physician or other qualified health care professional. It is a per-session code billed once per dialysis treatment episode when the physician or OQHCP performs a single clinical evaluation during the session.

The 90945 code covers the physician's complete management role during the peritoneal dialysis session assessing the patient, reviewing clinical parameters, issuing orders, documenting findings, and managing the treatment when that management is adequately accomplished through one evaluation. The patient's condition is generally stable enough that a single clinical assessment is sufficient to support safe and effective management of the session.

Where practices get into billing trouble with 90945 is in documentation. A claim for 90945 must have a complete, individually authored, dated, timed, and physician-authenticated evaluation note for that specific session. A nursing note, a treatment flowsheet alone, or a copied prior note does not meet the documentation standard. The physician's own evaluation must be present and specific to that encounter.

🩺  Typical Clinical Scenarios for CPT 90945

✔  AKI patient receiving acute peritoneal dialysis in the hospital — hemodynamically stable throughout the session with routine physician management

✔  ICU patient on CRRT for fluid management — stable session managed with a single physician evaluation and order set

✔  ESRD patient receiving acute peritoneal dialysis treatment outside of their normal home PD routine single evaluation during the acute session

✔  Hospital inpatient receiving hemofiltration for post-surgical fluid overload — one physician assessment during treatment

✔  Acute PD treatment in outpatient hospital setting for a patient with newly identified kidney failure prior to ESRD designation

03 — What Is CPT Code 90947?

CPT 90947 is defined as: Dialysis procedure other than hemodialysis (e.g., peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies) requiring physician or other qualified health care professional evaluation(s) with patient management during dialysis, with or without substantial revision of the dialysis prescription. This code applies when the dialysis session requires the physician to evaluate the patient on more than one occasion, actively manage an evolving clinical situation, and potentially revise the treatment prescription based on intra-session clinical findings.

The critical phrase in CPT 90947's definition is 'requiring physician evaluation(s)' — the plural is intentional and reflects the clinical reality it is designed to capture. Something changed or was at risk of changing during the session in a way that demanded the physician's return. That something whether a hemodynamic shift, a technical access problem, a fluid management crisis, or an adverse reaction must be documented explicitly. Billing 90947 based on clinical severity alone, without documentation of actual additional physician evaluations, constitutes upcoding regardless of how complex the patient's underlying condition is.

🚨  Warning — CPT 90947 Is High-Scrutiny

CPT 90947 is one of the most audited per-session dialysis codes in nephrology billing. Payers — including Medicare MAC contractors — specifically review 90947 claims for documentation of multiple, individually timed physician evaluations. A claim based on a single note, regardless of how detailed it is, does not meet the coding standard for 90947. The number and timing of physician evaluations during the session must be evident from the clinical record.

🩺  Clinical Scenarios That Justify CPT 90947

✔  Hemodynamic instability during peritoneal dialysis requiring physician return for re-evaluation and management decision

✔  CRRT circuit clotting or access failure requiring physician assessment and modified treatment parameters

✔  Patient develops respiratory distress during hemofiltration — physician evaluates, intervenes, and re-evaluates clinical status

✔  Fluid balance crisis during PD requiring intra-session prescription revision (dwell time, osmolarity, volume adjustment) with documented physician rationale

✔  Acute electrolyte emergency identified mid-session — physician returns for additional assessment, orders labs, and adjusts treatment

✔  Peritonitis suspicion during acute PD session — physician evaluates effluent, examines patient, adjusts management, and documents repeat assessment

04 — CPT 90945 vs 90947: Side-by-Side Comparison

Use this table as a quick reference for your billing and coding team when determining which code applies to a given peritoneal dialysis session.

Key Decision Rule: If the physician evaluated the patient once and the session proceeded without requiring a return visit bill CPT 90945. If the physician evaluated the patient, left, and then returned for an additional assessment based on a clinical change during the session or if the prescription was substantially revised mid-session bill CPT 90947, provided the documentation supports it.

05 — Documentation Requirements for CPT 90945 & 90947

The clinical record is the sole basis on which your 90945 and 90947 claims will be paid or denied. Payers review these codes at the documentation level what the physician wrote, when they wrote it, and whether it specifically reflects the encounter being billed. The checklist below is the documentation standard our billing team verifies for every peritoneal dialysis claim before submission.

🚫  Most Common Documentation Mistakes That Trigger Denials

✖  Submitting a nursing treatment note as the physician evaluation (nursing notes do not substitute for physician evaluation documentation)

✖  Copy-pasting a prior session's physician note with only the date changed (cloned documentation is a compliance violation in 2026)

✖  Billing 90947 with a single evaluation note regardless of how detailed it is (single note = 90945, not 90947)

✖  Missing timestamps on the second or third evaluation for a 90947 claim (each evaluation must be individually timed)

✖  No documented rationale for prescription revision in a 90947 claim (change alone is not sufficient — why it was made must be documented)

✖  ICD-10 code on the claim that is not supported in the clinical record (N18.6 requires ESRD diagnosis documented; N17.x requires AKI documentation)

06 — Step-by-Step Billing Workflow for CPT 90945 & 90947

01	Patient Evaluation & Session Initiation  — Physician evaluates the patient at the start of the dialysis session; establishes medical necessity, reviews treatment parameters, and documents the initial clinical assessment with time and signature
02	Eligibility Verification  — Billing team confirms active coverage, applicable payer type, ESRD enrollment status, coordination of benefits, and whether prior authorization is required by the payer for this dialysis modality
03	Real-Time Intra-Session Documentation  — Physician documents each evaluation as it occurs — with time stamps. Intra-session events (complications, parameter changes, clinical deterioration) are captured in real time, not reconstructed at session end
04	Documentation Review at Session Close  — After the session, billing team or QA staff reviews available documentation: How many physician evaluations occurred? Are all notes individually timed and authenticated? Is the clinical record complete?
05	CPT Code Selection  — Select based on documented evaluation count: one evaluation = CPT 90945; two or more evaluations or substantial prescription revision with documentation = CPT 90947. Never estimate — count from source records
06	ICD-10 Assignment & Medical Necessity  — Assign the primary diagnosis (N17.x or N18.6) supported by the clinical record. Add secondary codes for active comorbidities. Confirm medical necessity is evident from the clinical documentation
07	Modifier Review  — Assess modifier requirements: -25 if separately identifiable E/M performed same day; -59 for distinct procedural service; payer-specific modifiers. Verify each payer's modifier requirements individually
08	Claim Construction & Pre-Submit Scrubbing  — Build claim with CPT code, diagnosis codes, POS, rendering provider NPI, and date of service. Run through claim scrubbing software before submission — catch errors before they create denials
09	Electronic Submission & Active Tracking  — Submit electronically via clearinghouse. Confirm acceptance. Track claim status from submission through payer initial response. Flag claims that do not receive a response within expected timeframe
10	Payment Posting & Variance Review  — Post all payments and compare against expected reimbursement per code and per payer. Identify underpayments, short-pays, and contractual variances for follow-up
11	Denial Management & Root Cause Analysis  — Route denied claims to appeal within 5 business days. Document denial reason codes and track trends. Recurring denials signal systemic documentation or workflow issues — address upstream, not after the fact

07 — Reimbursement Rules for CPT 90945 & 90947 (2026)

We do not publish specific reimbursement dollar amounts because Medicare rates are updated annually through the Physician Fee Schedule and vary by geographic location, payer type, and contracted terms. Below is the framework your billing team should use to understand what drives payment on these claims.

08 — Common Billing Errors & Prevention Strategies

These are the errors our billing team most frequently corrects when conducting revenue cycle assessments on new nephrology billing accounts. Most have been recurring quietly for months before they are identified.

Billing Mistake	Revenue Impact	Prevention Strategy
Billing 90947 when only one evaluation documented	Default to higher code without reviewing documentation	Implement mandatory pre-submission documentation review; code must match evaluation count
Billing 90945 when multiple evaluations occurred	Coder does not review intra-session notes; undercoding	Per-session documentation review protocol identifies all timed evaluations before coding
Submitting nursing notes as physician evaluation	Billing team does not distinguish physician from nursing documentation	Only physician or OQHCP-authored, authenticated notes count; require note type verification
Copy-paste or cloned session documentation	Physician reuses prior note; AI payer tools flag identical content	Require individually authored notes per session; include CDI education in physician training
Missing timestamp on second evaluation for 90947	Physician documents second evaluation without time-stamping it	Train physicians: every evaluation during a session needs date, time, and signature
Wrong CPT family monthly code applied to acute session	Billing team unfamiliar with per-session vs. monthly code distinction	Monthly codes (90963-90966) are for home PD; per-session acute PD = 90945/90947
ICD-10 not supported in clinical record	Diagnosis submitted without corresponding clinical documentation	Pre-submission ICD-10 review confirms diagnosis is explicitly documented in the record
Incorrect or missing POS code	POS 21 vs 22 vs 65 not verified before submission	POS verification required in claim scrubbing checklist before all submissions
Late claim submission past timely filing window	Per-session claims not tracked; billing lag exceeds payer deadline	14-day maximum claim release target; automated aging alerts for unbilled sessions
Missing modifier when payer requires one	Team unaware of payer-specific modifier requirements	Maintain current payer-specific modifier reference; apply during claim build step

09 — Claim Denial Prevention Checklist

Every CPT 90945 or 90947 claim should clear this checklist before it is submitted. These are the specific failure points our team checks on every per-session peritoneal dialysis claim:

✅  Documentation Accuracy Checks

✔  Physician evaluation note is individually authored, patient-specific, and not a copy of a prior session note

✔  For 90947: two or more separately timed physician evaluations are documented in the record for this session

✔  All evaluation notes are dated, timed, and carry the treating physician's authenticated signature

✔  Dialysis procedure details (modality, parameters, treatment duration) are documented in the record

✔  Any intra-session clinical event that triggered a second evaluation is explicitly described in the documentation

✔  Prescription revision (if applicable for 90947) includes the original prescription, revised parameters, and clinical rationale

✅  Coding & Claim Accuracy Checks

✔  CPT code selected matches the documented evaluation count — 90945 for one evaluation, 90947 for multiple

✔  ICD-10 primary diagnosis is present in the clinical record and supported by the physician's documentation

✔  CPT code family is correct — per-session (90945/90947) for acute dialysis, not monthly home PD codes (90963-90966)

✔  POS code matches the actual service setting: POS 21 for inpatient, POS 22 for outpatient hospital

✔  Modifiers applied per payer-specific requirements — none missing, none incorrect

✔  No same-day monthly capitation code is being billed for the same patient by the same provider

✅  Eligibility & Compliance Checks

✔  Patient eligibility and active coverage confirmed for the date of service

✔  Prior authorization obtained if required by the payer for this dialysis modality

✔  Coordination of benefits is correct if Medicare is not the sole payer

✔  Timely filing deadline has not been exceeded for this date of service

✔  Claim has passed pre-submission scrubbing software without errors

✔  Internal QA review completed and documented before claim release

10 — Compliance Best Practices for CPT 90945 & 90947

🚨  CMS & OIG Audit Focus: Dialysis Billing

Per-session dialysis codes are a consistent focus area in CMS audit activity and OIG Work Plans. Billing 90947 without adequate documentation of multiple physician evaluations, or billing per-session codes when monthly capitation codes apply, are the two patterns most likely to attract MAC Targeted Probe and Educate (TPE) reviews or Recovery Audit Contractor (RAC) audit requests.

🛡️  Quarterly Internal Coding Audits  — Sample 90945 and 90947 claims each quarter — review documentation against billed code, confirm evaluation count matches the code, verify ICD-10 support. Catching errors internally before a payer does is the most cost-effective compliance investment available.

🛡️  Physician CDI Education  — Clinical Documentation Integrity (CDI) education specifically for peritoneal dialysis physicians should cover: the difference between 90945 and 90947, the time-stamping requirement for multiple evaluations, what constitutes a substantial prescription revision, and why cloned notes create compliance exposure.

🛡️  CMS Physician Fee Schedule Monitoring  — The Physician Fee Schedule is updated each January 1 with changes that can affect coding guidance, RVU values, and coverage requirements for dialysis codes. Monitoring these updates and adjusting billing workflows accordingly is a non-negotiable compliance responsibility.

🛡️  Record Retention — Minimum 7 Years  — CMS requires medical records supporting Medicare claims to be retained for a minimum of seven years from the date of service. This includes all physician evaluation notes, treatment records, orders, and dialysis flow sheets. State law may require longer retention periods.

🛡️  60-Day Overpayment Self-Disclosure  — If an internal audit reveals that 90947 was billed but the documentation only supports 90945, the 60-day rule requires prompt overpayment disclosure and return to CMS. Proactive self-correction is always preferable to externally identified overpayment.

11 — Why Nephrology Practices Outsource Dialysis Billing

Per-session peritoneal dialysis billing with its documentation-intensive requirements, per-evaluation tracking demands, and payer-specific policy variations is operationally difficult to sustain with an in-house generalist billing team. The practices that outsource this work to specialized nephrology billing partners consistently see lower denial rates, faster payment cycles, and better revenue capture than those managing it internally.

🏆  Why Nephrology Practices Choose MedCloudMD

Peritoneal dialysis billing is not a side function of nephrology revenue cycle management — it is a core revenue stream that requires dedicated expertise, documentation oversight, and payer-specific workflow precision to perform consistently. MedCloudMD was built for exactly this environment.

✔  Nephrology Billing Specialists — dedicated teams who understand CPT 90945, 90947, and the full dialysis code family, including their documentation standards and payer-specific rules

✔  Pre-Submission Documentation QA — every per-session dialysis claim reviewed for evaluation count, note completeness, ICD-10 support, and POS accuracy before submission

✔  Denial Management — denied claims routed to appeal within 5 business days; denial reason trends analyzed and addressed upstream in the workflow

✔  Coding Audits — quarterly internal audits of 90945 and 90947 claims to identify undercoding, overcoding, and documentation gaps before they attract payer attention

✔  Medicare Compliance Monitoring — we track CMS PFS updates, OIG priorities, and MAC billing bulletins and update your workflows accordingly, year-round

✔  Commercial Payer Authorization Support — prior authorization management for commercial plans requiring PA for dialysis modalities

✔  Accounts Receivable Follow-Up — per-session claim aging tracked; underpayments identified and followed up within appeal windows

✔  AI-Supported Workflow Optimization — technology-enhanced billing workflows that reduce manual error rates and accelerate claim release timelines

✔  Transparent Reporting — monthly revenue analytics specific to your dialysis billing volume, payer mix, and code utilization patterns

Explore our nephrology billing services: medcloudmd.com/specialties/nephrology-billing-services

12 — Frequently Asked Questions: CPT 90945 & 90947

Q1:  What is CPT Code 90945?

CPT 90945 is a per-session dialysis code that applies when a physician or other qualified healthcare professional provides a single evaluation during a dialysis procedure other than hemodialysis — including peritoneal dialysis, hemofiltration, and continuous renal replacement therapy (CRRT). It is billed once per session and covers all physician management delivered through that single evaluation.

Q2:  What is CPT Code 90947?

CPT 90947 applies to the same dialysis modalities as 90945 but requires that the physician or OQHCP perform multiple evaluations during the session, with active patient management and, when clinically indicated, substantial revision of the dialysis prescription. It reflects a higher level of physician involvement during the treatment than 90945 and requires documentation that specifically supports multiple, individually timed evaluations.

Q3:  What is the difference between CPT 90945 and 90947?

The sole clinical distinction is the number of physician evaluations during the session. CPT 90945 requires one documented evaluation. CPT 90947 requires two or more documented evaluations or one intensive management episode that includes a substantially revised dialysis prescription. The patient's underlying diagnosis severity does not determine the code; what the physician documented doing during the session does.

Q4:  Does Medicare reimburse CPT 90945?

Yes. Medicare Part B covers CPT 90945 as a physician service during non-hemodialysis dialysis procedures. Reimbursement is calculated using the code's assigned RVUs, the annual Medicare Conversion Factor, and the applicable GPCI for your practice location. Rates are updated each January 1 through the Physician Fee Schedule final rule — verify the current 2026 rate with your MAC.

Q5:  What documentation is required for 90945 and 90947?

For 90945: one complete, timed, dated, and physician-authenticated evaluation note documenting the clinical assessment and management decisions for that session. For 90947: two or more individually timed and authenticated physician evaluation entries, plus documentation of any intra-session clinical event that required the additional evaluation, and prescription revision rationale if applicable. ICD-10 diagnosis must be supported in the clinical record for both.

Q6:  What diagnosis codes are commonly associated with these codes?

ICD-10 N17.0, N17.1, N17.2, or N17.9 (Acute Kidney Injury subtypes) are commonly primary for hospital-based acute dialysis. N18.6 (End Stage Renal Disease) applies for ESRD patients receiving per-session acute management. Supporting secondary codes for comorbidities (hyperkalemia, fluid overload, sepsis, cardiac diagnoses) should be included when those conditions are addressed and documented during the session.

Q7:  What causes claim denials for 90945 and 90947?

The most common denial triggers include: billing 90947 when only a single physician evaluation is documented; submitting nursing notes as physician evaluations; copy-paste or cloned documentation; missing timestamps on evaluations; wrong code family (monthly PD code applied to acute per-session situation); missing or incorrect ICD-10; wrong place of service; and timely filing violations. Most are preventable with pre-submission documentation QA.

Q8:  Can CPT 90945 or 90947 be billed with other dialysis codes?

These codes should not be billed on the same day as monthly home dialysis capitation codes (90963-90966) for the same patient. They also cannot be billed with hemodialysis per-session codes (90935 or 90937) on the same day for the same session type. Modifier requirements and same-day billing restrictions vary by payer always verify with the specific payer before billing these codes alongside other services.

Q9:  How can nephrology practices improve reimbursement for these codes?

Key improvements include: requiring physicians to complete session-specific, time-stamped notes before claim release; implementing pre-submission documentation QA for every 90945 and 90947 claim; conducting quarterly coding audits to identify undercoding (eligible 90947 sessions billed as 90945); tracking denial reason codes by trend to drive systemic workflow corrections; and reviewing commercial payer underpayments monthly.

Q10:  When should providers outsource peritoneal dialysis billing?

If your practice is experiencing recurring denials on 90945 or 90947, inconsistent reimbursement, documentation gaps that slow claim release, or simply lacks the internal resources to maintain consistent per-session billing quality across a busy dialysis patient panel, outsourcing to a specialized nephrology billing partner is the most efficient path to improvement. Our team offers a no-cost billing assessment that identifies exactly where the gaps are. Contact us at medcloudmd.com/contact-us.

📌  Key Takeaways

✔  CPT 90945 = single physician evaluation during peritoneal dialysis or other non-hemodialysis procedure; CPT 90947 = multiple evaluations or active management with prescription revision

✔  Both codes are per-session — billed per dialysis treatment, not per month; do not confuse with monthly home PD codes 90963-90966

✔  Code selection is based entirely on what the physician documented doing during the session — one evaluation or multiple

✔  CPT 90947 requires separately timed, authenticated, individually authored physician evaluations — a single detailed note does not qualify

✔  Documentation that is cloned, unsigned, untimed, or authored by nursing staff will not sustain either code under audit

✔  Do not bill monthly home PD capitation codes on the same day as per-session 90945/90947 for the same patient

✔  Pre-submission QA — checking evaluation count, note quality, ICD-10, and POS — is the most effective denial prevention practice for these codes

✔  CMS record retention minimum is 7 years; per-session clinical records must be retained and retrievable on demand

⚖️  Disclaimer: This article is provided for general educational and informational purposes only and does not constitute legal, regulatory, compliance, financial, or professional medical coding advice. CPT codes 90945 and 90947, their documentation requirements, billing guidelines, and reimbursement policies are subject to annual updates by the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS). Requirements may also vary by payer, state, geographic location, facility type, and specific contractual or clinical circumstances. Healthcare providers, medical billing professionals, practice administrators, and compliance officers should independently verify all current coding, documentation, billing, and payer-specific requirements with their compliance officer, a Certified Professional Coder (CPC), their Medicare Administrative Contractor (MAC), or the applicable regulatory or professional authority before making coding or billing decisions. MedCloudMD makes no representations regarding specific reimbursement amounts for CPT 90945 or 90947, as payment rates vary by payer, location, annual CMS updates, and contractual terms. Clinical scenarios in this article are illustrative composites for educational purposes only. This content reflects publicly available CMS and AMA coding guidance as of 2026 and should not be relied upon as a substitute for current, verified guidance.