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RPA Comments on 2011 Medicare Fee Schedule Proposed Rule

Creation/Revision Date: August 24, 2010

Dr. Donald Berwick, Administrator 
Centers for Medicare and Medicaid Services 
Department of Health and Human Services 
Hubert H. Humphrey Building 
Room 314G 
200 Independence Avenue, SW 
Washington, DC 20201 

Re: CMS-1503-P: Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2011; Proposed Rule

Dear Administrator Berwick: 

The Renal Physicians Association (RPA) is the professional organization of nephrologists whose goals are to ensure optimal care under the highest standards of medical practice for patients with renal disease and related disorders. RPA acts as the national representative for physicians engaged in the study and management of patients with renal disease. We are writing to provide comments on selected portions of the 2011 Medicare Fee Schedule Proposed Rule. 

RPA’s comments will focus on the following issues: 

ESRD Related Services for Home Dialysis  
Addition of Kidney Disease Education to the List of Telehealth Services for 
CY 2011
2010 Elimination of Consultation Codes from the Fee Schedule
 ESRD Related Services for Home Dialysis

RPA concurs with CMS’ statements in the proposed rule pertaining to home dialysis patients that it is “clinically appropriate for the physician (or practitioner) to have at least one in-person, face-to-face encounter with the patient per month”, and would reflect “appropriate, high quality medical care for end-stage renal disease (ESRD) patients being dialyzed at home and generally would be consistent with the current standards of medical practice.” 

The typical ESRD patient on home dialysis has more physiological abnormalities than almost any “typical patient” in the Medicare beneficiary population, by virtue of being on dialysis with at least five significant co-morbidities, and having a polypharmacy regimen of at least seven medications. As such, RPA strongly believes that monthly face-to-face visits should be the standard of care for home dialysis patients. 

Acknowledging our support for the monthly visit to the home patient to serve as a standard of care, we also urge the Agency to provide the requirement with enough flexibility to account for the heterogeneity of patient care arrangements. The two situations that likely comprise the vast majority of instances when a monthly visit to a home patient is not achieved are (1) when there is significant geographic hardship; and (2) when the patient chooses not to participate in a monthly visit. 

Regarding geographic hardship, home dialysis patients in remote localities must travel hundreds of miles to be seen, or alternatively, their nephrologist must travel such distances to see them. The logistics, time, and practice expense associated with providing a face-to-face visit to these patients monthly can be prohibitive (to patients or nephrologists), and may act as a disincentive for Medicare ESRD beneficiaries and nephrologists to continue what are otherwise healthy working relationships. 

Nephrologists also cannot force their patients to attend a scheduled monthly visit. As such, we believe that if the patient does choose to opt out of the monthly visit, the nephrologist who has been performing all of the non face-to-face physician work tasks (such as review of labs, review of treatment data, review of the dialysis prescription, monitoring the patient’s vascular access, and overseeing quality improvement activities), as well as incurring the practice expense associated with managing the patient’s care, should not be penalized. We note that the Conditions for Coverage for ESRD Facilities, which also requires a monthly interaction between a clinician representing the facility and the home patient, does not find the facility to be out of compliance if the patient chooses to opt out of the patient visit, and we would urge CMS to align these policies. 

In summary, RPA supports the establishment of the monthly face-to-face visit as a standard of care for home dialysis patients. However, CMS should develop a policy with the flexibility to account for those situations where effective patient care arrangements are in place absent of a monthly visit.
Addition of Kidney Disease Education to the List of Telehealth Services for CY 2011

RPA commends CMS for its vision and foresight in adding the G-codes for individual and group kidney disease education (KDE) services (codes G-0420 and G-0421, respectively) to the Medicare telehealth services list. This change will promote the use of the KDE services and thus will improve patients’ preparation for renal replacement therapy (RRT) for those individuals with stage four chronic kidney disease (CKD). Further, it is another positive step in the integration of technological innovation and health information technology in healthcare delivery. 

2010 Elimination of Consultation Codes from the Fee Schedule

In the proposed rule, CMS recounts that it adopted a number of new payment policies for which it estimated the potential for a redistributive effect under the fee schedule, including the elimination of the reporting of all CPT consultation codes in order to allow for correct and consistent coding and appropriate payment for evaluation and management (E&M) services. As such, CMS indicated that to improve future fee schedule payment accuracy for services, the Agency was interested in public comments on the perspectives of physicians and nonphysician practitioners caring for Medicare beneficiaries using these services. 

RPA would assert that if CMS wants to appropriately reimburse specialists and subspecialists for services provided to vulnerable Medicare beneficiary populations with chronic diseases such as CKD, it should reconsider the decision to eliminate consultation codes from the fee schedule, as this change reduces payment accuracy. As described above, the typical ESRD patient is on dialysis with multiple (>5) significant co-morbidities and is on multiple (>7) medications. Recalling our comments on the 2010 Final Rule, to the extent that the nephrologist is being asked to render an expert opinion based on her/his additional years of training and experience in treating highly complex patients, equating the service associated with providing that opinion with an initial hospital visit or new patient office visit inherently reduces the intrinsic value of that expertise. This knowledge and expertise is distinct from that required for providing initial hospital and new patient visits, and of specific added value to the referring physicians' management of the patient. RPA believes that this devaluation of the subspecialists’ work and knowledge alone compromises the accuracy of the fee schedule. 

Further, this dichotomy between the values associated with consultation services prior to January 1, 2010 and those of the inpatient hospital visits or new patient office visits currently applies to all subspecialties treating those with chronic illnesses or otherwise vulnerable Medicare beneficiaries, such as endocrinology, rheumatology, infectious disease, and geriatrics. As such, RPA believes CMS should reconsider its decision to eliminate the consultation codes from the Medicare Fee Schedule in order to improve payment accuracy. 

As always, RPA welcomes the opportunity to work collaboratively with CMS in its efforts to improve the quality of care provided to the nation’s kidney patients, and we stand ready as a resource to CMS in its future endeavors. Any questions or comments regarding this correspondence should be directed to RPA’s Director of Public Policy, Rob Blaser, at 301-468-3515, or by email at


Edward R. Jones, M.D. 

CC: Barry Straube, M.D., Director and Chief Medical Officer, CMS
  Jonathan Blum, Director, CMS Center for Medicare Management
  Liz Richter, Deputy Director, CMS Center for Medicare Management
  Amy Bassano, CMS CMM Hospital and Ambulatory Policy Group

Renal Physicians Association

1700 Rockville Pike
Suite 220
Rockville, MD 20852

Phone: 301-468-3515
Fax: 301-468-3511

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