CMS Updates NCD 55: What Billing Teams Need to Know About Ultrafiltration, Hemoperfusion, and Hemofiltration Coverage

CMS has issued a modification to National Coverage Determination (NCD) 55, which governs Medicare coverage for ultrafiltration, hemoperfusion, and hemofiltration services. This update—effective March 12, 2026—clarifies the indications, limitations, and billing distinctions that determine whether these procedures are reimbursable under Medicare. If your facility or practice bills for dialysis-related services or treats patients with renal failure, drug overdose, or fluid management complications, this policy directly affects your revenue cycle.

Field	Detail
Payer	CMS (Centers for Medicare & Medicaid Services)
Policy	Ultrafiltration, Hemoperfusion and Hemofiltration
Policy Code	NCD 55
Change Type	Modified
Effective Date	2026-03-12
Impact Level	Medium
Specialties Affected	Nephrology, Critical Care, Emergency Medicine, Inpatient Hospital Billing, Outpatient Dialysis Facilities
Key Action	Review documentation practices for all three procedures to ensure claims align with CMS medical necessity criteria and covered indications before the effective date.

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CMS NCD 55 Overview: What These Three Procedures Are and Why Coverage Distinctions Matter

Before unpacking the billing implications, it helps to be clear on what each procedure involves—because CMS treats them very differently from a coverage standpoint.

Ultrafiltration removes excess fluid from the blood through a dialysis membrane using pressure. It is not a substitute for dialysis and is used when a patient cannot tolerate standard fluid removal during routine hemodialysis—most commonly in cases of refractory edema.

Hemoperfusion uses a charcoal or resin artificial kidney to remove toxic substances from the blood. It is most commonly used in life-threatening drug overdose scenarios, and coverage is available for patients with or without renal failure when that indication is met.

Hemofiltration removes fluid, electrolytes, and low molecular weight toxins from the blood. Like ultrafiltration, it intersects with dialysis services and carries specific billing rules around when a separate charge can be recognized.

Understanding these distinctions isn't academic—it determines whether your claim gets paid or denied.

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Medicare Coverage Criteria Under NCD 55: What Is and Isn't Covered

Ultrafiltration: Covered, But With Billing Restrictions

CMS has covered ultrafiltration under Medicare since September 1, 1979. However, the facility billing rules are strict. The Medicare composite dialysis rate is designed to cover the full range of complicated and uncomplicated nonacute treatments—which means no additional facility charge is recognized for predialysis ultrafiltration when performed in the same session as hemodialysis.

The exception is when medical complications require that ultrafiltration be performed separate from the dialysis treatment. In those cases, an additional charge can be recognized—but only if the claim is supported by documentation explaining why the ultrafiltration could not have been performed concurrently with dialysis.

This is a documentation trigger, not just a billing note. If your team cannot produce that clinical rationale in the medical record, expect the separate charge to be denied.

The physician's role also varies by patient stability:

#	Covered Indication Copy
1	Unstable patients may require physician presence at initiation and close proximity or in-house availability throughout.
2	Relatively stable patients (those with excessive weight gain between sessions) require only modest physician involvement beyond routine outpatient hemodialysis oversight.

Hemoperfusion: Covered for Drug Overdose, Not Covered for Routine Dialysis Enhancement or Iron Overload

Hemoperfusion coverage under NCD 55 is narrowly defined. Here's the breakdown:

Covered:

#	Covered Indication Copy
1	Life-threatening drug overdose, in patients with or without renal failure
2	Treatment of aluminum toxicity when used in conjunction with deferoxamine (DFO)—CMS has determined this use is clinically efficacious

Not Covered:

#	Covered Indication Copy
1	Used to improve the results of chronic hemodialysis—CMS has determined the clinical effects are unknown, and this falls outside the "reasonable and necessary" standard under §1862(a)(1) of the Act
2	Used in conjunction with DFO to treat iron overload, whether symptomatic or asymptomatic—CMS cites a lack of demonstrated efficacy and insufficient data

For hemoperfusion, CMS also expects physician presence at treatment initiation and in-hospital or adjacent office availability for the duration of the procedure, given the potential for sudden changes. One or two treatments are typically sufficient to clear the toxic compound; if additional treatments are needed, those must be documented with clinical rationale.

When hemoperfusion is performed concurrently with dialysis, payment reflects only the additional care rendered beyond what the dialysis covers—not a full separate procedure charge.

Hemofiltration: Covered Under Specified Conditions

The full policy text for hemofiltration was truncated in the available summary, but hemofiltration is generally a covered service when medically necessary and properly documented. Billing teams should obtain the complete NCD 55 policy text directly from CMS to confirm the precise criteria and limitations for this modality before the effective date.

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Benefit Categories and Care Settings Under NCD 55

This policy applies across multiple Medicare benefit categories:

• Inpatient Hospital Services
• Institutional Dialysis Services and Supplies
• Outpatient Hospital Services Incident to a Physician's Service

That means billing implications exist in both the inpatient and outpatient settings. Your RCM team needs to apply the correct billing rules depending on where the service is rendered—predialysis ultrafiltration billed from an outpatient dialysis facility carries different rules than the same service rendered during an inpatient stay.

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Affected Codes

The Centers for Medicare & Medicaid Services did not list specific CPT or HCPCS codes within NCD 55 as captured in this policy update. No ICD-10-CM diagnosis codes were enumerated in the available policy data either.

Action required: Contact your dialysis billing specialist or check the CMS Coverage Database directly to confirm which procedure codes your facility currently bills for these services. Map those codes against the coverage criteria above before March 12, 2026, to identify any claims at risk.

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What Your Billing Team Should Do

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