End Stage Renal Disease/ Dialysis Services CPT code and revenue code list

Services for the treatment of End Stage Renal Disease (ESRD), including outpatient dialysis
services (as defined by, but not limited to, the revenue and CPT codes below), require
notification.

No notification is required for end stage renal disease when a Medicare member travels outside
of the service area.

Dialysis:
90935, 90937, 4052F, 4054F – hemodialysis
90945, 90947, 4055F – peritoneal
90963 – 90970 – ESRD
90989 – patient training, completed course
90993 – patient training, per session
90999 – unlisted dialysis procedure, inpatient or outpatient

Revenue Codes:
304 – Nonroutine Dialysis
800 – 804, 809 – Renal Dialysis
820 – 825, 829 – Hemo/op or home
830 – 835, 839 – Other outpatient/peritoneal dialysis
840 – 845, 849 – Capd/op or home
850 – 855, 859 – Ccpd/op or home
880 – 882, 889 – Dialysis / misc

For the most current listing of UnitedHealthcare contracted dialysis facilities, please refer to our
online provider directory at UnitedHealthcareOnline.com or call us at (877) 842-3210. In an
effort to maximize member benefit coverage and lifetime maximum limits, we ask that you refer to
UnitedHealthcare contracted dialysis facilities whenever possible. Note that your agreement with
us may include restrictions on referring members outside the UnitedHealthcare network.

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