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Medicare Program: Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B fo

Creation/Revision Date: August 31, 2009

August 31, 2009

Ms. Charlene Frizzera 
Acting Administrator 
Centers for Medicare and Medicaid Services 
Department of Health and Human Services 
Hubert H. Humphrey Building 
Room 445G 
200 Independence Avenue, SW 
Washington, DC 20201

Subject:     CMS1413P; Medicare Program: Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2010; 
Proposed Rule

Dear Ms. Frizzera:

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 2010 Medicare Fee Schedule Proposed Rule.

RPA’s comments will focus on the following issues:

  • Budget Neutral Elimination of the Use of All Consultation Codes
  • Combined Impact of Provisions in the Proposed Rule on Interventional Nephrology Services
  • Proposals for Implementation of Kidney Disease Patient Education Programs
  • Electronic Prescribing Eligibility for Nephrologists
  • Reporting of Pediatric ESRD Measures in the 2010 PQRI 

Budget Neutral Elimination of the Use of All Consultation Codes 
Like many other medical specialty organizations, RPA is concerned about CMS’ decision to eliminate the use of all consultation codes in the fee schedule (with the exception telehealth consultation services.). We support the Agency’s efforts to increase payment for services provided by primary care physicians, and we are sympathetic to the issues raised by CMS in the proposed rule regarding its ongoing efforts to clarify Medicare guidance on documentation, billing, and transfer of care relating to consultation services. However, RPA believes that both the content and the precipitous nature of CMS’ decision are troubling.

Our primary concern relates to what we believe to be the devaluing of the consulting physician’s knowledge and opinion, whether he or she is a generalist, specialist, or subspecialist. To the extent that the consultant is being asked to render an expert opinion based on her/his additional years of training and experience, equating the service associated with providing that opinion with an initial hospital visit or new patient office 
visit does reduce 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. The reason that the consultation is being requested in the first place is that there is a higher level of specialized knowledge in the management of complex multisystem problems that 
necessitates the referring physician to seek the counsel of the consultant. While the associated work of inpatient/outpatient consultations and initial hospital visits and new patient office visits may be “clinically similar”, as CMS asserts in the rule, the training and experience providing the rationale for the consult request are not, and thus CMS’ proposal does devalue the services of the generalist, specialty or subspecialty consultant. 

Further, while we acknowledge both the history of consultation code refinement and CMS’ use of the formal rulemaking process to promulgate this change, it still seems that complete elimination of the consultation codes is a drastic step. RPA believes that it is important to bear in mind that the creation of the consultation code family was based on a desire to attend to the best interests of the Medicare beneficiary patient population. If a referring physician needed additional advice, recommendations, direction, or counsel in addressing the individual needs of a complex patient, over and above his or her level of expertise relative to the medical issue at hand, the consultation codes provided a pathway 
for obtaining that advice. It is RPA’s opinion that outright elimination of the pathway is fraught with the possibility of adverse unintended consequence. RPA therefore urges CMS to withdraw the proposal to eliminate consultation codes from the Medicare Fee Schedule prior to publication of the final rule.

Impact of Provisions in the Proposed Rule on Interventional Nephrology Services 
RPA unequivocally supports CMS’ mission of pursuing fiduciary responsibility as it administers the Medicare Trust Fund, and we recognize the complexities involved in developing a regulation the magnitude of the Medicare Fee Schedule in a climate full of competing priorities, legislative mandates, and regulatory constraints. However, we also believe it is the responsibility of the Agency to identify those areas where implementation of broad methodological change is adversely affecting both patient care and other initiatives being pursued by CMS. It is our opinion that the impact of the fee schedule changes on vascular access care provided by interventional nephrologists to Medicare 
beneficiaries with chronic kidney disease (CKD) is one of those areas, and we urge CMS to take steps to avoid this negative impact.

As the Agency knows, the Fistula First Breakthrough Initiative (FFBI) was created to increase the likelihood that every suitable patient will receive the optimal form of vascular access which, in most cases, will be a native arteriovenous fistula, or AVF. The focus of the FFBI is also on reducing central venous catheter use, vascular access complications, and their inherent morbidity and associated costs. In recent years a large proportion of these services have been provided in outpatient settings, either in specially-designed vascular access centers which operate as an extension of the physician practice, or as an ambulatory surgical center (ASC). This shift to the outpatient setting represents a tremendous advancement in the state of the art of vascular access care that benefits both patients and the Medicare program in general. Patients benefit not only from the 
avoidance of unnecessary hospital stays that would have been required only a few years previous, but also from the fact that these procedures are now provided by physicians with an extremely high degree of technical expertise, thus reducing the risk of complications and intuitively leading to improved patient outcomes. The Medicare program benefits from the savings resulting from reduced hospital admissions and the 
improved health of its beneficiaries.

According to the Fistula First website, in an effort to meet the CMS ‘stretch’ goal of an AV fistula use rate of 66% in hemodialysis patients, this rate has increased from approximately 15% when the program started in 2003 to 52% as of May 2009. The website goes on to note that “AVFs should be considered for every patient needing hemodialysis. AVFs last longer, need less rework or repairs, and are associated with lower rates of infection, hospitalization, and death.” RPA would assert that the increase of the AVF use rate is due in large part to advances in the use of vascular access services by interventional nephrologists, whose expertise with CKD and dialysis patients substantially enhances their understanding of the complexity of this care.

However, the ability of vascular access centers and interventional nephrologists to provide these services will be severely and negatively impacted by proposed methodological changes in the practice expense components of the applicable procedure codes. A snapshot review of the impacts for thirteen of the most commonly provided procedures in vascular access care indicates reductions in the practice expense values for these services ranging from 7% to 63%, with median reduction of 27% and a mean reduction of 20%. Estimates indicate that reductions of this magnitude could force the closure of up to 25% of vascular access centers, and accordingly reduce patient access to these services. While RPA as noted supports CMS’ mission of fiduciary responsibility and acknowledges the existence of systemic pricing anomalies for selected services provided by some specialties, we do not believe that this circumstance applies to the vascular access services provided by interventional nephrologists who extend their office practice to do so. If the interventional code reductions reduce the effectiveness of the 
vascular access center model, the result may well be that patients will not have the opportunity to maintain a noncatheter access through serial interventions.

Further, when viewed on a macro level, increased provision of these services to CKD patients does result in enhanced patient care as well as cost savings for the Medicare Trust Fund. Patient care improves, as access and fistula monitoring decreases thrombosis rates at facilities, which has an added benefit of not requiring patients to miss dialysis sessions when their access thromboses. Cost savings to the Medicare Trust Fund accrue from the reduction in thrombectomies overall, and from the provision of these services in the lower cost setting of the vascular access center or extension of the physician office.

The existence of the Medicare ESRD program is germane to consideration of these issues. For those CKD patients who have not yet advanced to ESRD, appropriate vascular access care can at a minimum frequently reduce the adverse physiological impact of their initiation to dialysis once started, and in many cases reduce the high mortality of such patients in the first 90 days on dialysis. For those patients who have already advanced to ESRD, appropriate vascular access care can result in lower rates of infection or hospitalization. According to the 2008 United States Renal Data System (USRDS) Data Report, the Medicare expenditure per patient per year for hemodialysis patients was approximately $72,000. Since Medicare is the primary payer for a majority of these patients, provision of any suite of services that can reduce the overall expense of 
dialysis should be promoted, rather than being subject to reductions of this nature. For all of these reasons, RPA urges CMS in the strongest terms possible to create a modifier, or some alternative pathway, to exempt service codes for vascular access procedures provided to CKD and ESRD patients from the reduction in practice expense values outlined in the proposed rule.

Proposals for Implementation of Kidney Disease Patient Education Programs 
RPA appreciates the Agency’s efforts to implement the new CKD patient education benefit established by Congress in the Medicare Improvements for Patients and Providers Act (MIPPA) in a way that is patient-centered and acknowledges the ongoing input from the kidney care community. We do believe however, that there are further changes within CMS’ authority to make that would result in substantially expanded patient access to these services. These changes are related to the pricing for the services, and the issue of possible certification for CKD education service providers.

RPA believes that CMS needs to revise the pricing structure outlined in the proposed rule for the CKD education services. We support the use of crosswalks in developing values for newly covered services, and using the medical nutritional therapy (MNT) benefit as crosswalk for the CKD educational services seems appropriate enough. However, as the Agency is certainly aware of by now, the time increments for the MNT benefit are only for 15 minute sessions of nutritionist time (30 minutes for group sessions), whereas the CKD education services are structured for 60-minute sessions of physician, physician assistant, nurse practitioner, and clinical nurse specialist time. Pricing of this nature is certainly not what CMS intended in developing this segment of the proposed rule. Even if the time increment for the CKD education services were set to match that of the MNT benefit (i.e., four times the 15-minute MNT increment to equal the 60-minutes for CKD education), it is unclear to RPA that the resulting reimbursement level would support the practice expenses involved in providing these services, but we believe that this would be an appropriate first step in appropriately pricing the services.

With regard to the specific RVU inputs for the CKD education services, RPA believes it is appropriate to crosswalk the work RVUs and direct practice expense (PE) inputs from the MNT codes. However, CMS should crosswalk the indirect practice expense per hour (PE/hr) inputs from the “all physicians” category to the services, as that category is more appropriate to physician services than the PE/hr for nutritionists or registered dietitians currently assigned to the MNT codes.RPA therefore strongly urges CMS to revise the time increments for pricing of the CKD education services to be at least equivalent to those of the MNT codes. RPA also urges CMS to directly crosswalk the work RVUs and the direct PE inputs for the CKD education services from the MNT codes, but to the PE/hr inputs from the “all physicians” category for the indirect PEs for these services.

With regard to the Agency’s request for comments on specific education and experience requirements for the enumerated qualified providers, we concur with the position of Kidney Care Partners (KCP) that CMS should require that qualified providers be either (1) board certified in nephrology or (2) have at least two years of experience working with patients with kidney disease. Such a requirement would ensure that educators have 
the background and experience necessary to meet the needs of patients with kidney disease without imposing unnecessary barriers or administrative complexity.RPA urges CMS to ensure that kidney disease educators are appropriately qualified to provide the CKD education services, without the creation of unnecessary requirements or obstacles to the provision of these services.

Electronic Prescribing Eligibility for Nephrologists 
RPA supports the adoption and use of health information technology such as electronic prescribing to improve patient safety and quality of healthcare and believes that the potential for additional payments by Medicare for the use of e-prescribing is an effective incentive for more widespread adoption. However, RPA is concerned that the current eligibility requirement may preclude the participation by the majority of practicing nephrologists.

The requirement that eligible professionals whose estimated allowed Medicare Part B charges for the e-prescribing measure codes, as defined by the e-prescribing denominator, must be at least 10% of their total Medicare Part B allowed charges will limit the ability of nephrology practitioners to participate in the incentive program because so little of their billed charges are reflected by the eprescribing measure codes. The proposed rule states that CMS is broadening the scope of the denominator codes to professional services that not only occur in the professional office and outpatient settings, but services furnished in skilled nursing facilities and the home care setting for 2010.

RPA commends CMS for expanding the scope of denominator codes, but is disappointed that CMS did not include professional services furnished in renal dialysis facilities in this expanded list of services. Nephrology practitioners routinely provide the outpatient services to Medicare beneficiaries intended to be captured by this program; however these unique set of services are reported through outpatient dialysis CPT codes not included in the e-prescribing measure denominator (CPT codes 90951-90970). RPA therefore urges CMS to address this eligibility requirement to ensure that the intent of the program, to urge adoption and use of electronic prescribing capabilities, is appropriately applied to all Medicare providers who routinely provide office and outpatient services to Medicare beneficiaries through expansion of the approved list of facilities to include renal dialysis facilities.

Reporting of Pediatric ESRD Measures in the 2010 PQRI 
RPA shares the concerns of the American Society of Pediatric Nephrology (ASPN) regarding the reporting of pediatric nephrology measures in the 2010 PQRI program. We believe that the fact that there are only two pediatric nephrologyspecific measures, combined with the requirement that one of the measures (hemodialysis adequacy) must be reported through the registry process, renders the participation of pediatric 
nephrologists in the PQRI program problematic if not impossible. As such, RPA believes that when less than three measures are applicable to a provider, only those measures representing indicators under the control of the submitting provider should be used until such time that there are sufficient measures to meet the primary standard.

We are also sympathetic to the concerns of ASPN that the registry process itself is not available to the vast majority of pediatric nephrologists, who practice in small, academic pediatric departments where no other pediatric faculty members care for Medicare beneficiaries. RPA supports ASPN’s recommendation that CMS change the reporting requirements for the pediatric ESRD hemodialysis adequacy measure so that it can be 
reported under the claims-based option for 2010. Currently CMS allows the second pediatric ESRD measure of influenza immunization to be reported in this individual manner.

We believe that this would allow more pediatric nephrologists to participate in the PQRI program and advance the ultimate goal of quality reporting. RPA urges CMS to ensure that when less than three measures are applicable to a provider, only those measures representing indicators under the control of the submitting provider should be used until there are sufficient measures to meet the primary standard, and to change the reporting requirements for the pediatric ESRD hemodialysis adequacy measure so that it can be reported under the claims-based option for 2010.

As always, we welcome the opportunity to work collaboratively with CMS in its efforts to improve the quality of care provided to the nation’s ESRD 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 3014683515, or by email at Director of Public Policy

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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