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RPA Comments on 2017 Medicare Fee Schedule Proposed Rule
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September 6, 2016

Andrew Slavitt 
Acting Administrator 
Centers for Medicare and Medicaid Services 
Room 445–G 
Hubert H. Humphrey Building, 
200 Independence Avenue, SW 
Washington, DC 20201 

RE: CMS-1654-P: Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare 
Advantage Pricing Data Release; Medicare Advantage and Part D Medical Low Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model 

Dear Acting Administrator Slavitt: 

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 kidney disease and related disorders. RPA acts as the national representative for physicians engaged in the study and management of patients with kidney disease. We are writing to provide comments on selected portions of the 2017 Medicare Physician Fee Schedule Proposed Rule. 

RPA’s comments focus on the following issues: 

    • Addition of Daily Dialysis Codes to Telehealth Service List 
    • Identification of ESRD Home Dialysis Services (CPT Codes 90963 Through 90970)
      as Misvalued Codes 
    • Proposed CMS Revisions of RUC-Recommended Values for Dialysis Circuit Codes 
    • Ongoing Reduction of Relativity Between Inpatient Dialysis Services and Associated
      Evaluation and Management Services 

Addition of Daily Dialysis Codes to Telehealth Service List 

RPA appreciates CMS’ proposal to add the CPT codes for daily dialysis services (Codes 90967-90970) to the list of category 1 telehealth services for 2017. Given that all of the other CPT codes in the dialysis service code family are designated as Category 1 telehealth services, this proposal will treat the daily dialysis codes in a manner consistent with the other codes in the code family. 
As noted in several of our comments pertaining to dialysis services and the telehealth designation in recent years, RPA steadfastly maintains its belief that the absence of the patient’s home or the dialysis facility from the list of approved originating sites for telehealth services vastly reduces the opportunities for any dialysis services to be furnished via telehealth means, and thus substantially limits the potential positive impact of this change, not to mention the limiting effect on the prevalence of home dialysis growth potential in general. We recognize that the list of approved originating sites for Medicare telehealth services is authorized by law and thus not within the purview of CMS to administratively revise, but would urge the Agency to recognize that the originating site limitation significantly curtails the potential benefit of such a policy revision for individuals with kidney failure. 

Identification of ESRD Home Dialysis Services (CPT Codes 90963 Through 90970) as Misvalued Codes 

In the proposed rule, CMS discusses a report developed by the Government Accountability Office (GAO) titled ‘‘END-STAGE RENAL DISEASE: Medicare Payment Refinements Could Promote Increased Use of Home Dialysis.” In the report GAO describes the current scenario in which home dialysis is an underused modality within the U.S. dialysis patient population broadly, notes the differences in payment amounts within the dialysis code family, states that this difference in payment rates may discourage physicians from prescribing home dialysis, and recommends review of these payment rates. CMS concurs and thus proposes to identify CPT codes 90963 through 90970 as potentially misvalued codes. 

RPA agrees that adult home dialysis is underutilized, and we are committed to increasing the percentage of adult dialysis patients in the U.S. on home therapies. RPA was a founding member of the Alliance for Home Dialysis, and has developed publications and tools such as our position paper on Increasing Hemodialysis Options for Patients with End-Stage Renal Disease and our tool for promoting the use of Kidney Disease Education (KDE) services in nephrology practices that highlight the benefits of home dialysis. It should be noted that home dialysis is not underutilized in the pediatric dialysis patient population 0-19 years old, where approximately 45% of all patients use home peritoneal dialysis (USRDS Annual Report 2015), so concerns regarding underutilization of home modalities should not apply to CPT codes 90963-90965 or 90967-90969 (the pediatric home and daily dialysis codes, respectively). 

However, RPA also believes that the causes of the underutilization are much more complex than the 10-15 percent payment difference in physician payment rates noted in the report would account for, as we do not envision that many nephrologists are mentally calculating the differences between home and in-center monthly capitated payments (MCPs) as treatment modality decisions are being discussed. Other factors that have impeded progress toward wider use of home dialysis therapies include: (1) gaps in nephrology training programs pertaining to home dialysis; (2) insufficient pre-dialysis patient education on all available dialysis modalities; (3) the inconsistency of dialysis facility cost report data associated with home dialysis, given its self-reported nature and inherent challenges in segregating cost report and staff time data specific to home dialysis from overall dialysis facility cost data; (4) the lack of infrastructure for appropriate staff support and supplies available to enable effective delivery of home therapies; (5) problems with the KDE benefit that have led to its underutilization and thus have likely had a negative effect on home dialysis downstream; (6) the current shortage of peritoneal dialysis (PD) solution in the U.S., which has compelled some nephrologists to defer from prescribing PD out of concern that limited availability of PD solution will force PD patients away from the modality of their choosing; and (7) that the originating site limitations of current Medicare telehealth policy require ESRD patients to travel for services regardless of whether dialysis services are designated as Category 1 telehealth services, and thus serves as a deterrent for home dialysis. 

Further, RPA is concerned that absent specific direction to CMS on how to revise these policies, payment for Medicare Part B services related to home dialysis will be substantially reduced. If CMS were to administratively set the payment rate for the adult home dialysis MCP at either the average payment for all MCP services or at the upper payment level (figures noted in the GAO report and cited in the proposed rule), this would provide a healthy Part B payment increase for home dialysis services, and probably enhance the incentives to provide this care (recalling that the pediatric home dialysis codes are not underutilized). RPA would be supportive of such a change as we believe that the current reimbursement does not consider the substantially increased burden of caring for a home- based patient, where there as much or more ‘hands-on’ care required by the nephrologist versus dialysis facility personnel and the intensity of that care, while provided in less visits, is no less involved than that for the in-center hemodialysis patient. However, we believe that the more likely scenario is that CMS would refer this issue to the AMA’s Relative Value Update Committee (RUC), and while RPA is a participant in and supporter of the RUC’s activities, it is a highly unpredictable process, and thus it is possible that RUC review would result in a recommended payment cut for home dialysis in the physician fee schedule. Given that the evident theme of the GAO report is to determine ways of promoting use of home dialysis, a reduction in payment for those services would obviously be counterproductive. 

RPA therefore urges CMS to either administratively set the payment rate for the adult home dialysis service in the fee schedule at levels more likely to promote their usage, or to direct the RUC to specifically address the adult home dialysis code solely in order to minimize the possibility that payment rates for home dialysis are decreased, and the possibility that pediatric home dialysis codes are adversely affected. 

Proposed CMS Revision of RUC-Recommended Values for Dialysis Circuit Codes 

Dialysis Circuit Code Family Work RVUs 

Codes 369x1 – x3 are the codes for diagnostic angiography, angioplasty, and stent placement in the dysfunctional but non-thrombosed dialysis fistula. They are commonly performed in patients who have problems with access flow, cannulation or bleeding. These procedures are scheduled electively – most commonly avoiding the patient’s dialysis day. Codes 369x1 – x3 are bundled codes, inclusive of and replacing codes 36147, 36148, 35476/75978, and 35475/75962 in dialysis access cases. 

Codes 369x4 – x6 describe thrombectomy of a thrombosed dialysis access. They are commonly performed when a patient presents for dialysis with an unrecognized thrombosed access and therefore requires an urgent procedure and unscheduled, extra dialysis treatment. They are bundled codes replacing CPT code 36870 but also including cannulation and angiography (36147, 36148) and intervention (when performed). 369x4 is thrombectomy without angioplasty or stent. 369x5 is thrombectomy with angioplasty. 369x6 is thrombectomy with angioplasty and stent. These codes are inclusive of all cannulation, catheterization, imaging, angioplasty and stenting within the dialysis access. 

Before addressing the individual physician work RVU’s proposed by CMS for each code, we want to point out two issues that significantly impact the appropriate valuation of these new bundled codes. 

First, RPA believes that there is compelling evidence for the higher RUC recommended physician work RVU for 369x1, and this also applies to the other codes (369x2 – x6), because the vignette developed by the CPT Panel does not accurately reflect the typical ESRD patient. According to the United States Renal Data System (USRDS) and other published data, the typical ESRD patient is >65 years old – not 45 years old. Additionally, they have multiple co-morbid medical problems, chronic debilitation, and are taking an average of 6-10 medications each day. The CPT Panel incorrectly described the typical ESRD patient as 45 years old rather than 65 years old. A younger, healthier patient in the CPT vignette likely led survey respondents to report less time. This would affect intra-service time to some extent, and to even greater extent the pre-service and post-service time. The frail, elderly ESRD patient requires careful pre- and post-operative physician evaluation and management not reflected in the inaccurate CPT vignette. [It is worth noting that as part of the CPT process RPA did submit an alternative ‘Option B’ proposal to CPT that was based on a 65 year old typical ESRD patient (attached), but CPT opted for the proposal sponsored by non-kidney disease related specialties that set the age for the typical patient at 45.] 

Secondly, we believe there is a bundling issue unique to the dialysis circuit family of codes 369x1 – x6. The dialysis circuit codes include all imaging and intervention within the dialysis access defined as originating in the artery adjacent to the arterial anastomosis, the cannulation areas, and all venous outflow to the axillary-subclavian vein junction. There is no code to recognize the work of “additional vessel” angioplasty or stent placement, or arterial angioplasty within the adjacent feeding artery. This is very different than the Open and Percutaneous Transluminal Angioplasty family of codes (CPT codes 372x1 – 372x4). Codes 372x2 and 372x4 describe arterial or venous angioplasty or (respectively) in each additional named vessel. This allows one to build a “typical” vignette with one angioplasty procedure, but appropriately allow reporting the additional work of intervention in a second or third lesion in separate vessels. The dialysis circuit is unique in that it has a number of different named vessels (arterial and venous) that can be in a direct single conduit or conduit with several branching channels. Because of the greater propensity for multiple lesions in the dialysis circuit than native arteries, it is appropriate to define the access vessel as CPT has done and allow reporting of only a single angioplasty or stent in that entire conduit. However, this creates a significant survey process problem that the RUC was unable to address. The survey built on the “typical patient” (51% of the cases) is unable to recognize the additional work of additional angioplasty or stent – even though it occurs with significant frequency. It is appropriate to recognize this unique dilemma in allowing the higher Intra-Work Per Unit of Time (IWPUT) and small differences in physician time seen with the RUC recommended work RVU’s and CPT code crosswalks. Taking these differences into consideration, the RUC recommended work RVU’s for codes 369x1 – x6 maintain appropriate relativity between the dialysis circuit code family (369x1 – x6) and the Open and Percutaneous Transluminal Angioplasty family of codes (CPT codes 372x1 – x4). 

Following is a code-by-code critique of the codes in the Dialysis Circuit code family: 


We believe that the CMS proposed work RVU of 2.82 undervalues the service of diagnostic angiography of the dialysis access 369x1. We understand CMS’ concern that the RUC recommended work RVU 3.36 would establish a new highest value when compared to other services with similar time. However, we believe the compelling evidence regarding CPT’s inaccurate description of the typical ESRD patient as 45 years old led to lower survey times and hence the “new highest value” problem mentioned by CMS. While we believe the RUC recommended value 3.36 should be accepted, if a lower work RVU is chosen the best code for crosswalk purposes is the reference code chosen by survey participants 36200 (Introduction of catheter, aorta) with work RVU 3.02. This procedure is very similar clinically in work and intensity to 369x1 despite its slightly higher intra-service time (30 minutes compared to 25 minutes). The code used by CMS as a crosswalk, colonoscopy through a stoma (CPT code 44388) has no relationship clinically despite similar intra-service time. This code is much less intense work than accessing an arterialized vessel and obtaining images from arterial anastomosis through the entire venous drainage including the central veins 369x1. 


We believe the CMS proposed work RVU of 4.24 undervalues the service of angiography and angioplasty of the dialysis access 369x2. We believe the same compelling evidence exists that CPT’s erroneous patient description in the vignette may have led survey respondents to under-report times. CMS discounts the RUC recommended crosswalk to code 43253 because while intra-service times are similar (40 minutes) the total time is longer for 43253 than 369x2. This difference in total time could be related to the vignette typical patient described as younger and healthier than is correct. Maintaining the RUC recommended work RVU 4.83 would lead to a higher increment of work RVU from 369x1. We believe that a higher increment in work RVU from 369x1 to 369x2 is appropriate because 369x2 is a bundled code that includes work unable to be accounted for in a survey on the typical patient. According to published literature, more than one stenosis is present requiring angioplasty in 20-30% of dialysis access cases. There are commonly more than one stenosis present in different vascular structures which are part of the dialysis access. Additionally, arterial angioplasty 35475 work RVU 6.60 is required when the feeding artery adjacent to the arterial anastomosis is stenotic. The higher increment in work RVU from diagnostic study 369x1 to diagnostic study with angioplasty 369x2 reflects the work of additional angioplasty on separate stenoses and arterial angioplasty in some cases – but which cannot be reflected in a “typical” 51% case vignette. Prior to the dialysis circuit family of codes being developed, the higher arterial angioplasty CPT code 35475 could be utilized if arterial angioplasty was performed within the dialysis access (though any venous angioplasty 35476 would then not be coded). However, there is no opportunity to make this distinction in the new code family including 369x2 despite the cases with arterial stenoses within the defined dialysis access being greater work. Finally, relativity with the Open and Percutaneous Transluminal Angioplasty family of codes (CPT codes 372x1 – 372x4) would be appropriate using the RUC recommended work value 4.83. We remind CMS that this family includes codes for “additional vessels” – angioplasty of multiple stenoses in different vessels is coded with 372x2 or 372x4 which may be used more than once. In the unique dialysis circuit code family, only one angioplasty 369x2 is allowed from feeding artery adjacent to the arterial anastomosis through the entire venous outflow to axillary-subclavian vein junction. 


We believe the CMS proposed work RVU of 5.85 undervalues the work of angiography with angioplasty and stent placement in the dialysis access 369x3. We again argue that there is compelling evidence that the CPT patient vignette does not reflect the typical patient (see prior comments under 369x1-2) and this may have impacted physician reported survey times. CMS based its rejection of the RUC recommended crosswalk 52282 work RVU 6.39 on the higher total time for this code which we believe is not correct. Additionally, in the Dialysis circuit code family, 369x3 includes all angioplasty and stenting done within the access. “Additional vessel” angioplasty or stenting work is included in 369x3 but not able to be captured in a survey utilizing the “typical” patient with a bundled code under these rules. This is not true for the Open and Percutaneous Transluminal Angioplasty family of codes where additional vessel stents would be coded with 372x4 (one or multiple). 


We disagree with CMS’ proposed work RVU of 6.73 based upon crosswalk to CPT code 43264. The RUC recommended value 7.50 is based upon the 25% of the survey results of 114 participants and supported by crosswalk comparisons more appropriate than CMS’ choice. It appears that CMS choice of crosswalk was in part a desire to maintain relativity with the lower work RVU’s assigned by CMS to 369x1 – x3. Assuming CMS uses a work RVU of 3.02 (the survey respondents reference service code 32000), this would lead to a ratio of 2.49 – only slightly higher than CMS’ proposed ratio of 2.4. We believe that this slightly higher ratio between 369x1 and 369x4 is appropriate, more accurately reflecting the significant intensity differences of the procedures done on dysfunctional vs. thrombosed accesses. 


We disagree with CMS’ proposed work RVU of 8.46 derived from comparison of intraservice time ratio between 369x1 and 369x5. The RUC recommended work RVU 9.00 is well supported as the 25th percentile of 114 survey respondents with good crosswalks to similar codes which demonstrate appropriate relativity. The survey times are adversely impacted by the CPT inaccuracy and RUC survey limitations discussed previously, but the RUC recommendation is appropriate when viewed from relativity perspective using RUC recommended work RVU for 369x1 (or crosswalk to 36200). Using CMS’s use of a 1:3 ratio stated in the proposed rule that would presumably triple the work of 369x1 ( when valued at a work RVU 3.02 noted in our comment above regarding 369x1), the resultant work RVU for 369x5 would be 9.06. This is nearly identical to the RUC recommended work RVU of 9.00. 


We disagree with CMS’ proposed work RVU of 9.88 based upon the RUC recommended increment of 7.06 from 369x1. The RUC recommended work RVU of 10.42 is well supported as the 25th percentile of 114 survey respondents with good crosswalks to similar codes which demonstrate appropriate relativity. Again, the survey times for this code are adversely impacted by CPT error and RUC survey limitations discussed previously. Using the RUC recommendation maintains appropriate relativity within the dialysis circuit code family and particularly the thrombectomy codes 369x4 – x6. 


We disagree with CMS’ proposed work RVU of 9.88 based upon comparison of intraservice time ratio to 372x4. We agree that the RUC recommended work RVU of 3.00 is incorrect as it is higher than 372x4. We believe that the work RVU should be identical to 372x4 which is 2.97. These two services are clinically identical. CMS’ comment that 369x7 would typically be a clinically less intense procedure is not correct as the intensity involved in both of these add-on codes is the work and risk of crossing the central venous stenosis and performing intervention within the thorax where complications could be severe. There is no difference in this work intensity based upon the direction of approach – from the dialysis access or from a native (femoral) vein. Both require advancing a long wire from the access site through the stenosis, superior and inferior vena cava, and right atrium. This is needed no matter which direction one is approaching the lesion as the tip of the wire must be parked in veins distal to the lesion in order to be certain to maintain access until good result and no complications are seen. From the dialysis access, the wire traverses the central vein stenosis, superior vena cava, right atrium, and is parked in the inferior vena cava. From the femoral vein, the wire traverses the inferior vena cava, right atrium, superior vena cava, central vein stenosis and is parked in the axillary vein. 


We agree with CMS’ proposed work valuation of 3.73 based upon the crosswalks from CPT code 93462 and 37222. 


We agree with CMS’ proposed work valuation of 3.48 based upon relativity concerns and crosswalk from CPT code 61797. 

RPA strongly urges CMS to reconsider the revisions it made to the work RVUs for service codes 369x1-369x-7. We believe change in this regard is necessary to address: (1) the use of a CPT typical patient vignette that substantially understates the age and health concerns of the typical ESRD patient; (2) the use of crosswalk codes different from those recommended by the RUC, and which are less similar to the new dialysis circuit codes than those the RUC suggested; and (3) the inequitable application of coding rules to the dialysis circuit code family regarding additional vessel stents that do not apply to the Open and Percutaneous Transluminal Angioplasty family of codes where services for additional vessel stents can be coded.

Dialysis Circuit Code Family Practice Expense RVUs 

Preservice Clinical Labor for Codes x4-6

These codes describe procedures performed on an urgent basis in a patient with a thrombosed dialysis access. This is different than codes x1-3 which describe procedures performed electively on patients with a dysfunctional dialysis access. The elective procedures are scheduled and planned well in advance of the procedure and performed on days that do not conflict with the patient’s dialysis schedule. However, the urgent procedures (369x4-6) are typically done when a patient presents to their dialysis treatment with a thrombosed access. They are unable to receive dialysis and an urgent call is placed by the dialysis facility to request thrombectomy. These procedures are typically done the same day so that the patient can receive dialysis within 12-24 hours and avoid hospitalization. The urgent nature of the procedure, need for additional preoperative testing because of missed dialysis, and need for arranging unscheduled dialysis treatment requires additional preservice time of the procedural staff. Arranging for an off schedule dialysis treatment is typically the responsibility of the procedural staff after the patient has been assessed in the preoperative area and the plan to restore or obtain dialysis access has been determined. 

L037D Clinical Labor to Prepare and Position Patient 

The RUC proposed additional 3 minutes are reasonable because these cases are done on the upper extremity using portable c-arm fluoroscopy. The additional time includes prepping and positioning the arm, applying appropriate shielding to the patient’s torso, positioning the c-arm unit, and then positioning other radiation shielding devices. Prepping the arm can be done in a number of fashions but typically requires 2 staff members. One staff member dons sterile gloves and holds the patient’s arm extended to the side and up off the arm board (many ESRD patients cannot hold their arm in this position for the time required to fully prep). Another staff member then preps the arm and hand including fingers with Chloroprep applicators, applies a sterile glove or towel to cover the hand, and then the patient’s arm is lowered into position on the arm board where it can be further draped for the procedure. Each of these activities require more time in the arm case than procedures done in the long plane of the body including the torso and legs. Three minutes is a more accurate reflection of the additional time than CMS’ proposed one minute. 

Thrombectomy Device (Treretola)

A mechanical thrombectomy device (Arrow Trerotola device is most typical) and a Fogarty thrombectomy balloon are both used in a dialysis access thrombectomy because they serve different purposes. The typical thrombosed fistula has an irregular vessel diameter that is filled with thrombus. A thrombectomy device is used to macerate this thrombus so that it can be aspirated or lysed. A pharmacologic agent may also be given to aid in thrombus lysis. This must be done prior to establishing inflow by removing the fibrin plug that forms at the arterial anastomosis. Once thrombus lysis through the body of the access is completed, it is safe to re-establish inflow by passing a Fogarty balloon catheter across the arterial anastomosis, inflating the balloon, and dragging it back into the access through the anastomosis. This maneuver dislodges the fibrin plug, allowing flow into the access. The Fogarty balloon is small and highly compliant allowing it to be pulled through the artery and into the access without damaging the vessels. The Trerotola thrombectomy device instruction for use (IFU) document suggests using either the Fogarty balloon or the thrombectomy device for removing the arterial plug. However, the IFU specifically states regarding using the device for removal of the arterial plug: 

“This procedure has been evaluated in 6 mm forearm loop grafts with brachial artery anastomosis. PRECAUTION: This technique may not be applicable to straight forearm loop grafts with radial artery anastomosis or tapered grafts”. 

A forearm loop graft is not the typical access in a thrombectomy case and therefore the device could only be used for this purpose in a minority of cases. Indeed, most operators do not believe that the thrombectomy device cannot be used safely for this function. This device is larger so risks pushing the fibrin plug into the artery if passed across the arterial anastomosis from the access – risking distal arterial embolization. The device is also much more rigid being made from metal and with irregular shape that risks damaging the endothelium of the artery causing arterial injury. The Arrow Trerotola device packaging specifically warns against The Fogarty balloon also is not effective as a thrombus maceration device because of its small size. Both a thrombectomy device and Fogarty balloon are required in the typical fistula thrombectomy case. 

Covered Stent 

Covered stents are the only stent devices that are FDA approved and supported by evidence from randomized controlled trials for use in dialysis access procedures. They are typically used in recurrent or elastic stenoses in dialysis access – and have become the standard of care for these interventions. They are also used to repair venous rupture caused by balloon angioplasty. According to a study performed by Braid Forbes Health Research of relevant CMS OPPS data, a covered stent was used 67.5% of the time and a bare metal stent is used 32.5% in the OPPS setting; RPA believes that this utilization pattern applies in the physician office, site-of-service 11 setting as well. This is the reason that a covered stent is included in 369x3 and 369x6. Bare metal stents are still used in central venous angioplasty because of concern that covered stents will occlude the internal jugular vein, and is the reason that the Cordis bare metal stent is included in 369x8. [i],[ii],[iii],[iv],[v],[vi]

Hemostatic Patch

Two hemostatic patches are required in thrombectomy procedures (369x4-6) because these procedures require two separate cannulations and sheaths. Opposing sheaths are placed in the access to allow clearing of thrombus in both the arterial and venous portions of the access. The two sheaths also allow imaging and interventions on the entire access. At the end of the case, both sheath sites are removed and covered with a hemostatic patch which aids in preventing bleeding and maintaining sterility. 

Chloroprep Applicator 26ml 

Chloroprep (2% Chlorhexidine gluconate in isopropyl alcohol) has become the typical solution used to prepare the arm and access site for these procedures (369x1-369x6). It has been demonstrated to be superior in preventing procedure related infections due to better antimicrobial properties and more prolonged effect on the skin. Dialysis patients are particularly susceptible to Staphylococcal infections which are common with catheter procedures. Chloroprep is different than Hibiclense solution which is 4% Chlorhexidine (no alcohol). The combination of Chlorhexidine and isopropyl alcohol has greatest efficacy as a preoperative skin prep in dialysis catheter and endovascular procedures. Chloroprep has become standard of care for these procedures. 


369x1 – 369x3 would typically utilize a micropuncture introducer kit that includes a 0.018” wire, a starter Bentson type 0.035” wire, and a hydrophilic 0.035” wire. Thrombectomy cases (369x4 – 369x6) require an additional 0.035” wire to cross the arterial anastomosis for imaging of the arterial inflow and interventions (commonly occurring) on the arterial side of the access. Once flow is established in the access by means of thrombectomy, a wire and catheter are passed through the access and across the arterial anastomosis so that contrast can be injected directly into the feeding artery. This allows one to image the peri-arterial dialysis access safely without risking embolization of retained thrombus if an occlusive retrograde contrast injection technique were to be used. Central venous angioplasty cases (369x7 – 369x8) require an additional 260cm wire in order to have adequate length to park the tip in the inferior vena cava. Placing the wire tip in this location is an important safety maneuver to ensure that the wire remains fully across the angioplasty site (in case of rupture) and does not extend into or through the right ventricle causing arrhythmia or bleeding into the pericardium. 

RPA would welcome the opportunity to discuss the issues described above in greater detail if that would be useful to CMS. 

Ongoing Reduction of Relativity Between Inpatient Dialysis Services and Associated Evaluation and Management Services

As discussed in previous rulemaking cycles, RPA continues to believe that the relationship between the family of inpatient dialysis services and the evaluation and management (E&M) service (CPT code 99232, level two hospital visit) that serves as its primary practice expense component code will continue to be out of alignment in 2017. Recall that in the Medicare Physician Fee Schedule Final Rule for CY 1995 published on December 8, 1994, and in Transmittal 1776, Change Request 2321 of the Medicare Claims Manual, HCFA/CMS states in both documents that: 

“We will bundle payment for subsequent hospital visits (CPT code 99231 through 99233) and follow-up inpatient consultations (CPT codes 99261 through 99263) into the fee schedule amounts for inpatient dialysis (CPT codes 90935 through 90947).” 

While follow-up inpatient consultations (CPT codes 99261 through 99263) have been deleted from the fee schedule for payment purposes, the subsequent hospital visit codes are of course still part of the fee schedule. However, as indicated in Addendum B for the 2017 fee schedule proposed rule, the PE RVUs for CPT code 90935 (inpatient hemodialysis, single evaluation, which serves as the anchor for the inpatient dialysis code family) are set at 0.48, while the PE RVUs for CPT code 99232 are 0.56, even though as the Agency noted above, payment for subsequent hospital component codes is supposed to be bundled into the payment for inpatient dialysis. 

RPA believes that the shortfall stems from the fact that for practice expense (PE) purposes the inpatient dialysis codes are treated as procedures when in fact they are both procedure and E&M services, as evidenced by the language above discussing the development of the inpatient dialysis code family based on E&M services. CPT codes 90935-90947 were made into combined E&M and procedure codes, with a single payment for the day encompassing the totality of both the full E&M services that day (including the PE) and the full procedure of that same day. Therefore, the ongoing loss of relative value is a significant problem, inappropriate and in need of just resolution by restitution of the full PE value increase. It is our belief that if the PE of the inpatient dialysis codes were specifically designated as E&M services, the rank order anomaly affecting the dialysis services and the rest of the E&M code family would disappear. 

We therefore urge CMS to restore the relativity between the appropriate E&M codes and the inpatient dialysis code family. 

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


Rebecca Schmidt, DO 


 Haskal ZJ, Trerotola S, Dolmatch B, Schuman E, Altman S, Mietling S, et al. Stent graft versus balloon angioplasty for failing dialysis-access grafts. N Engl J Med. 2010;362(6):494-503.

ii Vesely T, DaVanzo W, Behrend T, Dwyer A, Aruny J. Balloon angioplasty versus Viabahn stent graft for treatment of failing or thrombosed prosthetic hemodialysis grafts. J Vasc Surg. 2016.

iii Kim CY, Tandberg DJ, Rosenberg MD, Miller MJ, Suhocki PV, Smith TP. Outcomes of prosthetic hemodialysis grafts after deployment of bare metal versus covered stents at the venous anastomosis. Cardiovasc Intervent Radiol. 2012;35(4):832-8.

iv Shemesh D, Goldin I, Zaghal I, Berlowitz D, Raveh D, Olsha O. Angioplasty with stent graft versus bare stent for recurrent cephalic arch stenosis in autogenous arteriovenous access for hemodialysis: a prospective randomized clinical trial. J Vasc Surg. 2008;48(6):1524-31, 31 e1-2.

v Karnabatidis D, Kitrou P, Spiliopoulos S, Katsanos K, Diamantopoulos A, Christeas N, et al. Stent-grafts versus angioplasty and/or bare metal stents for failing arteriovenous grafts: a cross-over longitudinal study. J Nephrol. 2013;26(2):389-95.

vi Braid-Forbes Health Research (2016). Stent-Graft vs Bare Metal Stent Use in Hospital Outpatient Prospective Payment System Dialysis Access Stent Procedures. 


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