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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

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 a practice-specific review

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. Results in 14 days after the BAA, complete intake and agreed success criteria.

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

Enter your aging totals for an instant planning report. Uploaded files are processed locally; clinical intake is arranged separately.

Schedule 50-Claim PilotRun Free A/R Assessment
Scoped targets in writing Human review before submission HIPAA BAA Provided

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