Dialysis Monthly Capitation Payment (MCP) Tier Calculator

Under Medicare ESRD rules (42 CFR § 414.314 & CMS Chapter 8 § 140), nephrologists report outpatient dialysis management using tiered codes (CPT 90951–90962) dictated by age and documented face-to-face physician visits. When patients are hospitalized, Medicare prohibits full MCP codes and requires daily pro-rations (90967–90970). Calculate your exact tier allowable and recover lost downcoded revenue.

ESRD Monthly Capitation Payment (MCP) Engine

CMS Claims Processing Manual Chapter 8 § 140 & 42 CFR § 414.314

Patient Age Cohort

Dialysis Setting

Documented Face-to-Face Physician Visits

Inpatient Hospitalization Days in Month0 days hospitalized

Zero inpatient days: Full comprehensive monthly MCP allowable applies.

Active Dialysis Census85 patients

Downcoding Leakage Risk18%

MCP Fee Schedule ResultsPOS 65 / 12

Assigned Billing Code:CPT 90960

Monthly Allowable per Patient:$285.40

Total Monthly Census Revenue:$24,259

Annualized MCP Collections:$291,108

Annual Downcoding Revenue Loss:

-$22,356

Occurs when physicians complete 4+ rounds but clinic billing defaults to CPT 90962 due to lack of distinct face-to-face physician attestations.

Aethera Recaptured Cash:+$20,568/yr

Request Nephrology MCP Audit

ANSI X12 837P Professional Nephrology Claim Segment

Electronic Loop 2400 SV1 with Monthly Date Span & Place of Service 65

ISA*00* *00* *ZZ*NEPHROLOGY-EDI *ZZ*MEDICARE-MAC *260905*1230*^*00501*000000004*0*P*:~ GS*HC*NEPHROLOGY-EDI*MEDICARE-MAC*20260905*1230*1*X*005010X222A1~ ST*837*0004*005010X222A1~ BHT*0019*00*20260905004*20260905*1230*CH~ NM1*85*2*METROPOLITAN NEPHROLOGY GROUP*****XX*1629104928~ CLM*MCP-CLAIM-772*285.40***65:B:1*Y*A*Y*Y~ // LOOP 2400: MONTHLY CAPITATION PAYMENT (MCP) SERVICE LINE LX*1~ SV1*HC:90960*285.40*UN*1~ DTP*472*RD8*20260901-20260930~ // FULL MONTH COMPREHENSIVE OUTPATIENT ESRD MANAGEMENT SE*14*0004~ GE*1*1~ IEA*1*000000004~

Request Nephrology & Dialysis RCM Audit

Capture full 4+ visit MCP allowances, prevent hospital overlap recoupments, and streamline home dialysis billing.

Next Step For Your Practice

Turn these Dialysis MCP Tier Calculator insights into recovered cash

Are your nephrologists conducting 4+ dialysis visits but getting reimbursed at the 1-visit rate? Aethera delivers specialized nephrology RCM that audits rounding logs, captures complete MCP tiers, and automates hospital stay pro-rations. Let our senior AAPC-certified billing team audit 50 of your active claims or past denials — completely free, with guaranteed under-48-hour findings.

Free 50-Claim Audit Pilot

Test our scrub rules and appeal workflow on 50 real claims. Zero commitment, no credit card required.

Instant A/R Gap Analysis

Upload your aging report for instant benchmark comparisons against MGMA standards and recoverable cash projections.

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