ICD-10-CM N18.6 - End Stage Renal Disease (ESRD)

Code Description

Official Long Descriptor: End stage renal disease

Clinical Definition: Chronic, irreversible renal failure with long-standing and persistent renal disease with glomerular filtration rate (GFR) less than 15 mL/min

Applicable To: Chronic kidney disease requiring chronic dialysis

Code Hierarchy / Tree Structure

ICD-10-CM Hierarchy for N18.6

N00-N99     Diseases of the Genitourinary System
  └── N17-N19   Acute Kidney Failure and Chronic Kidney Disease
      └── N18       Chronic Kidney Disease (CKD)
          ├── N18.1   Chronic Kidney Disease, Stage 1
          ├── N18.2   Chronic Kidney Disease, Stage 2 (Mild)
          ├── N18.3   Chronic Kidney Disease, Stage 3 (Moderate)
          │   ├── N18.30  Stage 3 Unspecified
          │   ├── N18.31  Stage 3a
          │   └── N18.32  Stage 3b
          ├── N18.4   Chronic Kidney Disease, Stage 4 (Severe)
          ├── N18.5   Chronic Kidney Disease, Stage 5
          ├── N18.6   End Stage Renal Disease (ESRD) ← THIS CODE
          └── N18.9   Chronic Kidney Disease, Unspecified

Parent Code: N18 - Chronic Kidney Disease (CKD)

Code Range: N17-N19 - Acute Kidney Failure and Chronic Kidney Disease

Chapter: Chapter 14 - Diseases of Genitourinary System (N00-N99)

Coding Guidelines & Instructions

Use Additional Code

Z99.2 - Dependence on renal dialysis (to identify dialysis status)
- Hemodialysis status
- Peritoneal dialysis status
- Presence of arteriovenous shunt for dialysis
- Renal dialysis status NOS

Code First (When Applicable)

Diabetic Chronic Kidney Disease: E08.22, E09.22, E10.22, E11.22, E13.22
Hypertensive Chronic Kidney Disease: I12.-, I13.-

Use Additional Code (If Applicable)

E88.A - Associated cachexia
Z94.0 - Kidney transplant status

Important Coding Rules

If both a stage of CKD and ESRD are documented, assign code N18.6 only
N18.6 is assigned when the provider has documented end-stage renal disease (ESRD)
Do not code N18.5 (CKD Stage 5) with N18.6 - N18.6 takes precedence
Patients on chronic dialysis are automatically classified as ESRD

Type 1 Excludes (Never Code Together)

Code	Description
N18.5	Chronic kidney disease, stage 5 (when requiring chronic dialysis)
N17.-	Acute kidney failure
N19	Unspecified kidney failure (when end-stage is documented)

Note: Type 1 Excludes means “NOT CODED HERE” - these conditions cannot be coded together with N18.6

Type 2 Excludes (May Code Together If Both Present)

Code	Description
P96.0	Congenital renal failure
N14.-	Drug- and heavy-metal-induced tubulo-interstitial and tubular conditions
R39.2	Extrarenal uremia / Prerenal uremia
D59.3-	Hemolytic-uremic syndrome
K76.7	Hepatorenal syndrome
O90.41	Postpartum hepatorenal syndrome / Renal failure following labor and delivery
T79.5	Posttraumatic renal failure
N99.0	Renal failure postprocedural

HCC (Hierarchical Condition Category) Information

CMS-HCC Risk Adjustment Model (2026)

For CY 2026, CMS will calculate 100% of risk scores using the 2024 CMS-HCC model (V28)

HCC Category	Description	ICD-10 Codes	RAF Score Impact
HCC 136	Chronic Kidney Disease, Severe (Stage 4)	N18.4	~0.289 (Community, Non-Dual, Aged)
HCC 137	Chronic Kidney Disease, Stage 5	N18.5, N18.6	~0.288-0.456
HCC 138	Chronic Kidney Disease with Complications	N18.5, N18.6 with complications	Variable

HCC Mapping for N18.6

N18.6 maps to HCC Categories 136, 137, and 138

Risk Adjustment Factor (RAF) Impact:

Average Medicare patient has RAF score of approximately 1.0
Complex patients with multiple conditions including ESRD reach RAF scores of 2.5 to 4.0
N18.6 is a significant RAF score driver due to high expected costs of ESRD care

2026 HCC Model Changes

Full implementation of CMS-HCC Version 28 on January 1, 2026
V28 model uses more recent fee-for-service data
Some HCC categories were reorganized and renumbered in V28
N18.6 remains a high-risk HCC category under V28

MS-DRG Assignments for N18.6 (MS-DRG v43.0)

MS-DRG	Description	MCC/CC Status	Relative Weight (Approx.)
008	Simultaneous Pancreas and Kidney Transplant	-	High
019	Simultaneous Pancreas and Kidney Transplant with Hemodialysis	-	High
673	Other Kidney and Urinary Tract Procedures with MCC	MCC	~2.5-3.0
674	Other Kidney and Urinary Tract Procedures with CC	CC	~1.5-2.0
675	Other Kidney and Urinary Tract Procedures without CC/MCC	None	~1.0-1.5
682	Renal Failure with MCC	MCC	~1.8-2.2
683	Renal Failure with CC	CC	~1.3-1.7
684	Renal Failure without CC/MCC	None	~0.9-1.2

DRG Impact Notes

N18.6 can serve as a Major Complication/Comorbidity (MCC) when not the principal diagnosis
Proper sequencing of N18.6 is critical for DRG assignment
When N18.6 is the principal diagnosis, MS-DRG 682-684 typically apply
Common coding error: Using N18.5 instead of N18.6 for patients on dialysis can result in incorrect DRG assignment

Monthly Capitation Payment (MCP) Codes - Outpatient Dialysis

CPT Code	Description	Age Group	Visits Required	wRVU (2026)	Est. Reimbursement	Assistant Payable
90951	ESRD services, complete monthly	< 2 years	4+ visits	Varies	Varies	No
90952	ESRD services, 2-3 visits	< 2 years	2-3 visits	Varies	Varies	No
90953	ESRD services, 1 visit	< 2 years	1 visit	Varies	Varies	No
90954	ESRD services, complete monthly	2-11 years	4+ visits	Varies	Varies	No
90955	ESRD services, 2-3 visits	2-11 years	2-3 visits	Varies	Varies	No
90956	ESRD services, 1 visit	2-11 years	1 visit	Varies	Varies	No
90957	ESRD services, complete monthly	12-19 years	4+ visits	Varies	Varies	No
90958	ESRD services, 2-3 visits	12-19 years	2-3 visits	Varies	Varies	No
90959	ESRD services, 1 visit	12-19 years	1 visit	Varies	Varies	No
90960	ESRD services, complete monthly	20+ years	4+ visits	6.82	$227.79	No
90961	ESRD services, 2-3 visits	20+ years	2-3 visits	3.57	$119.24	No
90962	ESRD services, 1 visit	20+ years	1 visit	2.00	$66.80	No

Home Dialysis MCP Codes

CPT Code	Description	Age Group	wRVU (2026)	Assistant Payable
90963	Home dialysis, complete monthly	< 2 years	Varies	No
90964	Home dialysis, complete monthly	2-11 years	Varies	No
90965	Home dialysis, complete monthly	12-19 years	Varies	No
90966	Home dialysis, complete monthly	20+ years	Varies	No

Partial Month / Transitional Codes

CPT Code	Description	Age Group
90967	ESRD services, less than full month	< 2 years
90968	ESRD services, less than full month	2-11 years
90969	ESRD services, less than full month	12-19 years
90970	ESRD services, less than full month	20+ years

Assistant Surgeon Payable Status

ESRD MCP codes (90951-90970) are NOT assistant surgeon payable

These are management/capitation codes, not surgical procedures
Only one MCP service permitted per calendar month per patient
Cannot be billed by multiple physicians for the same patient in the same month

2026 ESRD PPS Base Rate

ESRD Prospective Payment System (PPS) Base Rate: $281.71

Represents approximately 2.2% increase from 2025
Applies to bundled dialysis facility payment (not physician E/M)
Physician work RVUs affected by -2.5% efficiency adjustment

Documentation Requirements for MCP Codes

Required Documentation Elements

Face-to-face visits must be documented with date of service
Dialysis adequacy assessment must be documented (Kt/V or URR)
Review of dialysis prescription effectiveness
Assessment of:
- Blood pressure management
- Anemia management
- Mineral bone disease
- Vascular access function
- Nutrition status
Medication reconciliation
Plan of care for the month

Common Denial Reasons

Missing dialysis adequacy documentation (Kt/V or URR)
Billing more than one MCP per calendar month
Incorrect visit count for code selected
Missing modifier -JW or -JZ for single-dose vials
Billing TCM (99495/99496) and full MCP in same month by same provider

Coding Examples

Example 1: ESRD Secondary to Diabetes

Principal Diagnosis: E11.22 - Type 2 diabetes mellitus with diabetic chronic kidney disease
Secondary Diagnosis: N18.6 - End stage renal disease
Secondary Diagnosis: Z99.2 - Dependence on renal dialysis

CPT: 90960 - ESRD services, complete monthly (4+ visits, age 20+)

Example 2: ESRD Secondary to Hypertension

Principal Diagnosis: I12.0 - Hypertensive chronic kidney disease with stage 5 CKD or ESRD
Secondary Diagnosis: N18.6 - End stage renal disease
Secondary Diagnosis: Z99.2 - Dependence on renal dialysis

CPT: 90961 - ESRD services, 2-3 visits per month (age 20+)

Example 3: ESRD Post-Kidney Transplant Failure

Principal Diagnosis: N18.6 - End stage renal disease
Secondary Diagnosis: Z94.0 - Kidney transplant status
Secondary Diagnosis: Z99.2 - Dependence on renal dialysis

CPT: 90961 - ESRD services, complete monthly (age 20+)

Example 4: ESRD with Anemia

Principal Diagnosis: N18.6 - End stage renal disease
Secondary Diagnosis: D63.1 - Anemia in chronic kidney disease
Secondary Diagnosis: Z99.2 - Dependence on renal dialysis

CPT: 90962 - ESRD services, 1 visit per month (age 20+)

Example 5: Home Dialysis Patient

Principal Diagnosis: N18.6 - End stage renal disease
Secondary Diagnosis: Z99.2 - Dependence on renal dialysis

CPT: 90966 - Home dialysis, complete monthly (age 20+)

Common Coding Scenarios

Scenario 1: CKD Stage 5 vs ESRD

Documentation	Correct Code	Rationale
”CKD Stage 5, not on dialysis”	N18.5	Patient not requiring dialysis
”CKD Stage 5, on hemodialysis”	N18.6	Patient requires chronic dialysis
”ESRD”	N18.6	ESRD automatically implies dialysis requirement
”CKD Stage 5 and ESRD”	N18.6 only	N18.6 takes precedence

Scenario 2: Diabetes + Hypertension + ESRD

When all three conditions are documented:
1. Code the diabetic CKD first: E11.22 (or appropriate diabetes code)
2. Code N18.6 for ESRD
3. Hypertension is assumed related to CKD - use combination code if documented

Scenario 3: Acute on Chronic Kidney Disease

If patient has ESRD with acute kidney injury:
- N18.6 - End stage renal disease
- N17.9 - Acute kidney failure, unspecified (if documented)
- Z99.2 - Dependence on renal dialysis

Note: Both can be coded as N17.- is Type 2 Excludes

Quality Measures & Reporting

Measure ID	Description	Related CPT Codes
329	Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis	90957-90962, 90966, 90970
ESRD PPS	ESRD Prospective Payment System Quality Incentive Program	All ESRD MCP codes

Required ICD-10-CM for ESRD Quality Measures

N18.6 - End stage renal disease
Z49.31 - Encounter for adequacy testing for dialysis

Billing & Reimbursement Notes

Medicare Coverage

N18.6 is a billable/specific ICD-10-CM code
Effective for dates of service on or after October 1, 2015
2026 edition effective October 1, 2025

MCP Billing Rules

Only ONE MCP code per calendar month per patient
Based on number of face-to-face visits during the month
Payment made AFTER the month has passed
Cannot bill if dates of service are prior to month end
All physicians involved in care must coordinate to avoid duplicate billing

Modifier Requirements

Modifier	When to Use
-JW	Single-dose vial with discarded amount (ESAs, IV iron)
-JZ	Single-dose vial with NO waste (required for compliance)
-95	Telemedicine (audio and video)
-AQ	Service in Health Professional Shortage Area

Clinical Pearls

Key Clinical Facts

ESRD represents the most severe form of chronic kidney disease
GFR < 15 mL/min defines ESRD
Patients require renal replacement therapy (dialysis or transplant)
ESRD is irreversible without kidney transplantation

Common Comorbidities to Document

D63.1 - Anemia in chronic kidney disease
E21.0 - Primary hyperparathyroidism (secondary to ESRD)
N25.81 - Secondary hyperparathyroidism of renal origin
I12.0 - Hypertensive chronic kidney disease with ESRD
E08-E13 with .22 - Diabetes with diabetic chronic kidney disease
Z94.0 - Kidney transplant status (if applicable)
Z99.2 - Dependence on renal dialysis (ALWAYS code with N18.6)

Code History

Year	Effective Date	Change
2016	10/1/2015	New code (first year of non-draft ICD-10-CM)
2017-2026	10/1 annually	No change
N18.6 has remained stable since ICD-10-CM implementation

Adjacent ICD-10-CM Codes

Code	Description
N17.9	Acute kidney failure, unspecified
N18.1	Chronic kidney disease, stage 1
N18.2	Chronic kidney disease, stage 2 (mild)
N18.30	Chronic kidney disease, stage 3 (moderate)
N18.4	Chronic kidney disease, stage 4 (severe)
N18.5	Chronic kidney disease, stage 5
N18.6	End stage renal disease
N18.9	Chronic kidney disease, unspecified
N19-	Unspecified kidney failure
Z99.2	Dependence on renal dialysis
Z94.0	Kidney transplant status
Z49.-	Encounter for care involving renal dialysis

Common Associated CPT Codes

CPT	Description
90960	ESRD monthly, 4+ visits, age 20+
90961	ESRD monthly, 2-3 visits, age 20+
90962	ESRD monthly, 1 visit, age 20+
90966	Home dialysis monthly, age 20+
90970	ESRD services, per day (partial month)
36821	AV fistula creation
36832	Revision, AV fistula
93922	Duplex scan of hemodialysis access

Audit Risk Areas

High-Risk Documentation Issues

Incomplete dialysis adequacy documentation (Kt/V or URR missing)
Incorrect visit count for MCP code selected
Duplicate MCP billing by multiple providers
Missing Z99.2 when patient is on dialysis
Using N18.5 instead of N18.6 for dialysis patients
Billing TCM and MCP in same month by same provider

Documentation Best Practices

Document ALL face-to-face visits with dates
Include dialysis adequacy measures in monthly assessment
Clearly document ESRD diagnosis (not just “CKD”)
Code Z99.2 for all patients on chronic dialysis
Sequence underlying etiology first (diabetes, hypertension) when applicable

Quick Reference Summary

Field	Value
Code	N18.6
Description	End Stage Renal Disease
Billable	Yes
HCC Categories	136, 137, 138
HCC Model	CMS-HCC V28 (2026)
MS-DRGs	673, 674, 675, 682, 683, 684, 008, 019
Required Additional Code	Z99.2 (dialysis status)
Code First	Diabetes (E08-E13.22), Hypertension (I12.-, I13.-)
MCP CPT Codes	90960, 90961, 90962 (age 20+)
Assistant Payable	No
Effective	10/1/2015 (current through 2026)

Explorer

N18.6