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RPA 2010 Medicare Fee Schedule Comments

Creation/Revision Date: December 29, 2009

December 29, 2009 

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

Subject: CMS-1413-FC Medicare Program; Revisions to Payment Policies Under the Physician Payment Schedule and Other Revisions to Part B for CY 2010; Final 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 Final Rule. 

RPA’s comments will focus on the following issues:

  • Elimination of All Consultation Codes from the Fee Schedule
  • Impact of Changes for Final Rule on Interventional Nephrology Services
  • Implementation of Kidney Disease Patient Education Program
  • Electronic Prescribing Eligibility for Nephrologists
  • Reporting of Pediatric ESRD Measures in the 2010 PQRI

Elimination of the Use of All Consultation Codes from the Fee Schedule

RPA continues to share the concerns of most of organized medicine regarding CMS’ decision to eliminate the use of all inpatient and outpatient consultation codes in the fee schedule. As noted in our comments on the proposed rule, we support the Agency’s efforts to increase payment for services provided by primary care physicians, and are sympathetic to the issues raised by CMS in the proposed rule regarding ongoing efforts to clarify Medicare guidance on documentation, billing, and transfer of care relating to consultation services. However, RPA believes that there has been an absence of clarity, forethought, and sufficient preparation in advance of the elimination of the consult codes. RPA’s specific concerns are:

  • The delayed and insufficient communication on the part of the Agency with regard to carrier and provider education on the removal of the consults. Dissemination of the contractor instruction transmittal (December 15) and the Medlearns Matters article for providers (December 17) occurred less than three weeks prior to implementation of the change;
  • The lack of clarity in addressing those situations when Medicare is a secondary payer and the primary private payer is still using the consultation codes, as well as those situations where consultations occur emanating from interactions in the emergency department and observation settings;
  • CMS has not apparently accounted for the possibility that the devaluation of consultative services in general would seem to invariably lead to a disinclination on the part of ‘consulting’ subspecialties to provide these services, possibly reducing the standard of care for vulnerable patient populations such as patients with end-stage renal disease (ESRD) and geriatric patients;
  • The absence of any stated plan on CMS’ part to track the impact of the change, including data gathering the likely diminished granularity of Medicare claims reporting.

As noted in our comments on the proposed rule, we are primarily concerned with the devaluing of the consulting physician’s knowledge and opinion. 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 inherently reduces the intrinsic value of that expertise. 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. 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. 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 consulting physician. 

RPA recognizes that underlying concerns with the use of the consultation codes historically are the catalyst for CMS proposing to eliminate the codes from the fee schedule, and that the Agency used a formal rulemaking process with full opportunity for public comment to promulgate this change. That said, it still seems that complete elimination of the consultation codes is a drastic step with potential for considerable adverse consequences for Medicare beneficiaries. The fundamental reason that a consultation is typically requested is that the patient has a single or series of complex medical issues. As such these patients are by definition in a vulnerable state of health, whether in the short term or longitudinally. RPA believes that to implement a change of this scope and magnitude to an aspect of the care delivery system disproportionately treating vulnerable groups of patients seems to invite operational problems that will disrupt and fragment care. RPA therefore urges CMS to delay implementation of the proposal to eliminate consultation codes from the Medicare Fee Schedule prior to January 1, 2010. 

Impact of Provisions in the Proposed Rule on Interventional Nephrology Services 

RPA commends CMS for implementing several methodological revisions that have in large part ameliorated proposed reductions in value that would have affected several categories of services, including those provided by interventional nephrologists to promote effective vascular access care. We believe that CMS’ decisions to (1) use a four-year transition for implementing the changes flowing from use of the Physician Practice Information Survey (PPIS) survey data; (2) implement changes in assumptions governing equipment utilization benefitted vascular access care; and (3) apply the rate change only to diagnostic equipment (such as MRIs and CT scans) and not therapeutic equipment (such as those utilized in a freestanding vascular access centers) all serve to promote the health outcomes of patients receiving vascular access care. 

The benefits of these changes in renal care are multiple. One result is that the outpatient setting is preserved as a viable locale for vascular access care, as in recent years a large proportion of these services have been provided in outpatient settings such as vascular access centers or ambulatory surgical centers (ASCs). This shift to the outpatient setting represents a tremendous advancement in 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. CMS’ own Fistula First Breakthrough Initiative (FFBI) is promoted by the overall progress in the state of the art of vascular access care. For all of these reasons RPA applauds the Agency’s policy vision and willingness to refine proposals in a way beneficial to Medicare beneficiaries with chronic kidney disease (CKD) and the providers treating them. 

Implementation of Kidney Disease Patient Education Program 

RPA again commends the Agency for its revaluing of the pricing structure for the newly covered kidney disease education (KDE) services. We believe that the revised relative value unit (RVU) levels for these services will substantially increase the likelihood that nephrology practices will be able to provide the services to a degree that will tremendously increase access to this care, and thus provide meaningful benefit to the CKD patient population. Among the potential results of effective CKD patient education are: (1) a reduction in the adverse physiological impact of initiation to dialysis once started; (2) in many cases reduced mortality of such patients in the first 90 days on dialysis’ and (3) delayed onset of the patient’s need for dialysis. For these reasons, RPA congratulates CMS on appropriate refinement of the values assigned to the KDE service codes. 

Electronic Prescribing Eligibility for Nephrologists 

As noted in our comments on the fee schedule in recent years, RPA supports the adoption and use of health information technology such as electronic prescribing to improve patient safety and quality of healthcare. We believe that the potential for additional payments by Medicare for the use of e-prescribing is an effective incentive for more widespread adoption. However, RPA must reiterate our long held concern that the current eligibility requirement precludes the widespread 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 e-prescribing measure codes. The final 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 also for services furnished in skilled nursing facilities and the home care setting for 2010. 

RPA supports expansion of the scope of denominator codes, but we continue to be 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 reconsider and revise 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 nephrology-specific 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. Making this change 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 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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