90935

Hemodialysis procedure with a single evaluation by a physician or other qualified health care professional

CPT code 90935 describes a hemodialysis procedure that includes a single evaluation of the patient by a physician or other qualified healthcare professional (QHP) during the treatment session. Hemodialysis is a life-sustaining medical intervention used to treat patients with end-stage renal disease (ESRD) or acute kidney injury (AKI). The procedure involves the extracorporeal removal of waste products, such as urea and creatinine, and excess water from the blood when the kidneys are unable to perform these functions. During the session, the patient's blood is pumped through an artificial kidney, known as a dialyzer. Inside the dialyzer, a semi-permeable membrane separates the blood from a dialysis solution (dialysate). Waste products move from the blood into the dialysate via diffusion, while excess fluid is removed through ultrafiltration. The professional service represented by 90935 includes the physician's or QHP's assessment of the patient's clinical status, review of the dialysis prescription (including dialysate composition, blood flow rates, and fluid removal targets), and monitoring for any complications during the procedure, such as hypotension, muscle cramps, or vascular access issues. This code is specifically utilized when the physician performs only one such evaluation during the dialysis treatment. If the physician must return for a second or subsequent evaluation due to a change in the patient's condition or to perform additional assessment, code 90937 would be appropriate instead. This code is commonly reported in the inpatient setting or in outpatient settings when the global monthly capitated payment (MCP) for ESRD does not apply.

Clinical Indications

  • End-stage renal disease (ESRD) requiring maintenance dialysis
  • Acute kidney injury (AKI) with metabolic acidosis
  • Severe hyperkalemia or other refractory electrolyte imbalances
  • Fluid overload unresponsive to diuretics, often associated with congestive heart failure
  • Uremic pericarditis or encephalopathy
  • Specific drug toxicities or poisonings (e.g., ethylene glycol, lithium, salicylates)

Procedure Steps

  1. Review the patient's medical history, current laboratory values (electrolytes, BUN, creatinine), and previous dialysis flow sheets.
  2. Assess the patient's vascular access site (fistula, graft, or catheter) for signs of infection, patency, and bruit/thrill.
  3. Determine the dialysis prescription parameters, including treatment duration, dialyzer type, dialysate composition, and ultrafiltration goals.
  4. Perform a physical examination of the patient while they are connected to the hemodialysis machine, focusing on volume status and cardiovascular stability.
  5. Monitor the patient's vital signs and the machine's pressure readings throughout the initial phase of the procedure.
  6. Address any clinical issues that arise during the single evaluation, such as adjusting the fluid removal rate or managing symptomatic hypotension.
  7. Document the evaluation findings, the dialysis parameters, and the patient's response to the treatment in the medical record.

Coding Guidelines

  • Use 90935 for a single evaluation during the hemodialysis procedure.
  • If the physician performs more than one evaluation during the same dialysis session, report 90937 instead of 90935.
  • Hemodialysis codes (90935, 90937) include the evaluation and management (E/M) services related to the dialysis procedure and the renal failure on the day of dialysis.
  • A separate E/M service may be reported only if the patient's condition is unrelated to the renal failure and requires significant, separately identifiable work; in such cases, modifier 25 should be appended to the E/M code.
  • For chronic outpatient dialysis, these codes are not used if the physician is billing under the monthly capitation payment (MCP) codes (90951-90970).
  • Do not report 90935 in conjunction with 90945, 90947 (peritoneal dialysis) for the same treatment session.

Associated ICD-10 Codes