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RPA Comments on the 2012 Medicare Physician Fee Schedule Proposed Rule

Creation/Revision Date: August 30, 2011

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August 30, 2011 

Donald Berwick, MD 
Centers for Medicare and Medicaid Services 
Department of Health and Human Services 
Attention: CMS-1524-P 
Mail Stop C4-26-05 
7500 Security Boulevard 
Baltimore, MD 21244-1850 

Subject: CMS-1524-P Medicare Program; Revisions to Payment Policies Under the Physician Payment Schedule and Other Revisions to Part B for CY 2012; Proposed Rule 

Dear Dr. 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 2012 Medicare Fee Schedule Final Rule. 

RPA’s comments will focus on the following issues:  

Loss of Relativity Between Inpatient Dialysis Services and Associated Evaluation and Management Services 
Impact of Changes Affecting Vessel Mapping Services on Vascular Access Care and the Fistula First Breakthrough Initiative
Proposed Solution to Remove Barrier Impeding Nephrologist Participation in CMS EHR Incentive Program
Loss of Relativity Among Inpatient Dialysis Services and Associated Evaluation and Management Services 

As noted in RPA’s comments on the Medicare Fee Schedule over the last several years, we continue to be troubled by the loss of relativity in the Medicare Resource-Based Relative Value Scale (RBRVS) as it pertains to the primary inpatient dialysis code (CPT code 90935, hemodialysis, single evaluation) and the inpatient evaluation and management (E&M) services that are a typical component of this dialysis code. A review of what has occurred in recent years indicates that in 2004 the value for CPT code 90935 was roughly equivalent to a level three subsequent hospital visit (CPT code 99233). Due in part to increases in the practice expenses for E&M codes over a several year period; by 2010 the total value for 90935 was less than that of a level two subsequent hospital visit (CPT code 99232). RPA pursued our concerns through the appropriate channels by surveying nephrologists to determine the physician work and practice expense associated with providing inpatient dialysis services. We presented our findings to the AMA’s Relative Value Update Committee (RUC) in October 2009, and were pleased that the RUC acknowledged the validity of our concerns and partially restored the relative relationship of the inpatient dialysis codes to the inpatient E&M codes. 

However, the fee schedule proposed rule indicates that in 2012 and when the practice expense RVUs are fully implemented in 2013, the RVUs in both years will fall for the inpatient dialysis codes and rise for CPT code 99232, with the net result that the relativity between these codes will again be lost in 2012 and the disparity exacerbated in 2013. Thus, the most commonly used dialysis code, CPT code 90935, will be valued less than one of its component services. RPA strongly believes that the practice expenses for the inpatient dialysis codes should not be less than that for CPT code 99232, a concept validated in practice by the RUC, and we therefore urge CMS to ensure that the relativity between the inpatient dialysis codes and their component E&M services is maintained. 
Recommendation: RPA recommends that CMS restore the relative relationships between CPT code 90935 (hemodialysis, single evaluation), CPT code 99232 (level two subsequent hospital visit), and CPT code 99233 (level three subsequent hospital visit).
Impact of Changes Affecting Vessel Mapping Services on Vascular Access Care and the Fistula First Breakthrough Initiative 

In the proposed rule, CMS includes within a discussion of its methodology for development of code-specific RVUs a specific outline for how work, practice expense, and malpractice values are developed for G-codes. This passage notes that crosswalks are initially utilized to develop PE RVUs, and that once data is available, CMS crosswalks the direct PE inputs and develops PE RVUs using the regular practice expense methodology, including allocators that are derived from utilization data. The section includes a list of G-codes with RVUs developed in this manner, and subsequently notes that while the codes on the list were insulated in CY 2011 from adjustments related to Medicare Economic Index (MEI) rebasing and revising, CMS was proposing to implement these adjustments in 2012 to develop more accurate payment rates for these services relative to other fee schedule services. Service code G0365 (Vessel mapping 
of vessels for hemodialysis access) is among the codes on this list, and as a result of the adjustment, the total RVUs for G0365 will be reduced by over 17%. It is also worth noting that the value for the vessel mapping (G0365) was originally crosswalked from upper extremity sonography with no consideration for contrast imaging of peripheral veins or combination studies, and thus from our perspective substantially understating associated practice expense. 

RPA is concerned about this reduction due to the critically important role that vessel mapping services plays in the successful creation of arteriovenous (AV) fistulae. Studies indicate that vessel mapping identifies vessels suitable for an AV fistula for a majority of patients for whom a physical exam itself did not classify the patient as being a candidate for an AV fistula, and that mapping vessels can significantly increase the incidence of successful AV fistulae. The issue of successful AV fistula placement is of sufficient consequence that CMS itself is a leading partner in the Fistula First Breakthrough Initiative (FFBI) program, whose mission is to promote the use of AV fistulae, which, according to FFBI, “last longer, need less rework or repairs, and are associated with lower rates of infection, hospitalization, and death.” 

While RPA appreciates CMS’ commitment to its fiduciary responsibilities and to seeking the greatest degree of accuracy possible in the development of relative values for all services included in the Medicare Fee Schedule, we urge the Agency to consider the impact of the reduction for vessel mapping services on a programmatic level. At a juncture where the FFBI is making every effort to advance the use and success of AV fistulae, a reduction in the relative values and ultimately the reimbursement for a critically important component of that care is counterproductive in terms of both patient care and efficient use of overall Medicare program resources. RPA therefore urges CMS to not implement the proposed adjustment affecting vessel mapping services. 
Recommendation: RPA recommends that CMS defer from implementing the proposed 2012 adjustment in practice expense value for service code G0365 (Vessel mapping of vessels for hemodialysis access) and maintain the value for this service at the 2011 level.
Proposed Solution to Remove Barrier Impeding Nephrologist Participation in CMS EHR Incentive Program 

As CMS is likely aware, there is an unintended impediment to nephrologist participation in the CMS EHR Incentive Program resulting from the “50%” rule implemented in the EHR program and the fact that many nephrologists provide a majority of their services in dialysis facilities. RPA believes that this issue can be addressed administratively by the Agency and we urge CMS to do so. 

Specifically, participation in the EHR Incentive Program requires that at least 50% of the eligible professionals’ patient encounters during the reporting period occur in a location(s) or practice(s) equipped with a certified EHR. Typically, nephrologists provide care within a dialysis facility to patients with end stage renal disease (ESRD), and given the complexity associated with this chronic condition, these patients are often seen weekly in the dialysis facility. However, dialysis facilities are not considered eligible providers within the context of the CMS EHR Incentive Program. This confluence of facts requires the nephrologist striving to demonstrate meaningful use to bring his/her certified EHR into the dialysis facility, so that the 50% rule can be accommodated within the framework of the ambulatory rules for physician eligible providers. Unfortunately, this also creates duplicative data entry (with data being entered in both the physicians EHR and the dialysis facility information system) resulting in not only unnecessary administrative overhead, but also potentially could be the cause of medical errors that otherwise would not occur. Ultimately, this scenario creates a substantial barrier to both adoption and meaningful utilization of the physician EHR. 

An interim solution to this problem would be to incorporate the unique patient encounter concept within the eligibility requirement. The problem is substantially mitigated if the participation requirement is interpreted as “at least 50% of the eligible professional’s unique patient encounters during the reporting period occurring in a location(s) or practice(s) equipped with a certified EHR.” Such a solution would not only benefit nephrologists, but all other providers delivering care to patients with chronic diseases in venues of care excluded from participating in the CMS EHR Incentive Program. This would result in more widespread adoption and utilization rates of certified EHRs among nephrologists and other chronic disease providers. 
Recommendation: RPA urges CMS to interpret the EHR Incentive Program participation requirement as “at least 50% of the eligible professional’s unique patient encounters during the reporting period occurring in a location(s) or practice(s) equipped with a certified EHR” to facilitate the participation of nephrologists in the EHR Incentive Program.
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

Thank you, 

Ruben Velez signature
Ruben L. Velez, MD 

Renal Physicians Association

1700 Rockville Pike
Suite 220
Rockville, MD 20852

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

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