90945

Dialysis procedure; hemodialysis, inpatient, for an unstable patient, per day

CPT code 90945 describes a complete hemodialysis procedure provided to an inpatient who is medically unstable. This includes all physician pre-, intra-, and post-dialysis services, such as evaluation of the patient's condition, prescription of the dialysis, management of fluid and electrolyte balance, monitoring for complications, and necessary adjustments to the treatment plan. The term 'unstable patient' implies a critical clinical status requiring heightened physician presence, frequent reassessments, and immediate intervention for conditions such as severe hypotension, arrhythmias, acute respiratory distress, severe electrolyte imbalances, or significant bleeding, often necessitating care in an intensive care setting. This code is reported per day, regardless of the number of runs or length of dialysis on that day.

Clinical Indications

  • Acute kidney injury (AKI) with life-threatening complications (e.g., severe uremia, hyperkalemia, metabolic acidosis, fluid overload unresponsive to diuretics, uremic encephalopathy, uremic pericarditis).
  • End-stage renal disease (ESRD) requiring emergent dialysis due to acute complications or inability to tolerate outpatient dialysis settings.
  • Poisoning with dialyzable toxins (e.g., methanol, ethylene glycol, lithium, salicylates) causing severe metabolic derangements and organ dysfunction.
  • Severe fluid overload refractory to other therapies, leading to respiratory compromise or cardiac dysfunction.
  • Profound electrolyte abnormalities (e.g., hyperkalemia, severe hypernatremia/hyponatremia, hypercalcemia) resistant to conservative management and posing immediate life threats.
  • Septic shock or other critical illness with associated acute kidney injury and systemic instability requiring close medical supervision during dialysis.

Procedure Steps

  1. Comprehensive patient assessment to determine the need for emergent or urgent dialysis and to evaluate the patient's current hemodynamic and metabolic status.
  2. Establishment or verification of vascular access (e.g., central venous catheter insertion or existing fistula/graft assessment).
  3. Prescription of dialysis parameters, including dialysate composition, flow rates, ultrafiltration goals, and anticoagulation, tailored to the unstable patient's needs.
  4. Initiation of hemodialysis, typically in an intensive care unit (ICU) or other monitored inpatient setting.
  5. Continuous monitoring of vital signs, hemodynamic status, fluid balance, and laboratory parameters throughout the dialysis session.
  6. Active management of potential complications during dialysis, such as hypotension, arrhythmias, hypoxemia, or access-related issues.
  7. Frequent physician reassessments and adjustments to the dialysis prescription based on the patient's dynamic clinical condition.
  8. Termination of the dialysis session and post-dialysis patient assessment and management, including medication adjustments and further diagnostic planning.

Coding Guidelines

  • CPT code 90945 is for physician services for hemodialysis provided to an *unstable* inpatient, per day.
  • This code encompasses all physician professional services related to the hemodialysis procedure for that day, including evaluation, supervision, and management of complications, regardless of the number of runs or duration.
  • Do not report 90945 in conjunction with E/M codes (99202-99499) for services primarily related to the dialysis on the same day by the same physician.
  • If multiple dialysis sessions occur on the same day for an unstable inpatient, only one unit of 90945 should be reported.
  • Distinguish from 90935 (hemodialysis, inpatient, stable patient) based on the patient's clinical instability requiring intensified physician presence and management.
  • The medical record documentation must clearly support the patient's 'unstable' status and the intensive level of physician involvement required.
  • This code does not include facility services, supplies, or technician services, which are separately billable by the hospital.

Associated ICD-10 Codes