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RPA Comments on the 2015 Medicare Fee Schedule Final Rule

Creation/Revision Date: September 02, 2014

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September 2, 2014 

Marilyn B. Tavenner, Administrator 
Centers for Medicare and Medicaid Services 
Department of Health and Human Services 
Attention: CMS-1612-P 
P.O. Box 8013 
Baltimore, MD 21244-8013 

Re: CMS-1612-P: Revisions to Payment Policies under the Physician Fee Schedule, 
Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models & Other Revisions to Part B for CY 2015; Proposed Rule 

Dear Administrator Tavenner: 

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 kidney disease. We are writing to provide comments on selected portions of the 2015 Medicare Physician Fee Schedule Final Rule. 

RPA’s comments will focus on the following issues: 

 • Payments for Physicians and Practitioners Managing Patients on Home Dialysis 
• Chronic Care Management 
• CMS Methodology for Calculation of Direct Practice Expenses 
• Ongoing Reduction of Relativity Between Inpatient Dialysis Services and Associated Evaluation and Management Services 

Payments for Physicians and Practitioners Managing Patients on Home Dialysis

RPA commends CMS for its decision to allow the monthly capitation payment (MCP) physician or practitioner to bill for the age appropriate home dialysis MCP service (as described by CPT codes 90963 through 90966) for the home dialysis (less than a full month) scenario if the MCP physician or practitioner furnishes a complete monthly assessment of the end-stage renal disease (ESRD) beneficiary and at least one face-to-face patient visit. This policy revision not only appropriately aligns the policy for home patients to be consistent with partial month scenario policy for center-based dialysis patients, but also is another step toward removing any possible policy-based barriers to dialysis patients moving to the home setting. 

Use of Chronic Care Management in Kidney Care 

RPA is encouraged by and supports CMS’ creation of chronic care management (CCM) service codes in the fee schedule. The nephrology specialty has decades of experience with addressing issues related to chronic illness and providing care on a non face-to-face basis in a capitated payment environment. As such, we have been able to offer our perspective within the AMA CPT and Relative Value Update Committee (RUC) structures on both the CCM codes and the transitional care management (TCM) codes developed for implementation in the 2013 MFS, and we believe the Agency’s proposals for CCM codes are a positive and reasonable step forward in this area. 

There are two issues specific to kidney disease care pertaining to the CCM codes that RPA would like CMS to address. The first relates to the use of these codes in the treatment of non-ESRD chronic kidney disease (CKD). While RPA concurs with the Agency that care management services are captured with the MCP for ESRD services (CPT code 90951-90970), this does not apply to services provided to CKD patients who do not yet have ESRD. RPA believes that use of the CCM codes to treat non-ESRD CKD would represent an effective investment of Medicare resources in that to the extent it facilitates the ability of nephrologists to delay the onset of ESRD, not only would the care of CKD patients be greatly enhanced, but also the savings to the Medicare program would likely be substantial. We therefore urge CMS to affirm that the CCM codes would be appropriate for use in non-ESRD CKD. 

Additionally, RPA urges CMS to permit billing for both ESRD services and CCM if the CCM services are not in the same period covered by the ESRD services. For example, if a face to face encounter with a home dialysis patient is not achieved in a month for any reason, the ESRD services are not billable, despite the fact that the nephrologist will have performed all of the chronic care management services associated with home dialysis care. Currently, nephrologists caring for patients with ESRD often serve as a primary care provider—and it would be particularly important for these clinicians to provide CCM services if ESRD services are not billable during a month. 

Most patients with kidney disease have multiple other serious chronic co-morbidities, including hypertension, diabetes, and various cardiovascular disorders, and they are among the most likely patient populations to benefit from more coordinated, comprehensive care. Given those circumstances, we urge CMS to ensure that the CCM codes are as widely usable as practicable in the treatment of kidney disease. 

CMS Methodology for Calculation of Direct Practice Expenses 

RPA would like to comment on two aspects of CMS’ calculation of practice expense (PE) relative value units in the proposed rule. First, CMS utilizes a formula to obtain the direct PE RVU that multiplies actual PE (labor, supplies, and equipment costs) by a budget neutrality factor. While we agree with the basic premise of utilizing resource based actual costs in calculating the practice expense, the budget neutrality adjustment has the effect of reducing payment for adjusted labor, adjusted supplies, and adjusted equipment to a level significantly below actual cost to providers. Indeed, the budget neutrality adjustment that CMS has proposed for 2015 reduces payment to 59% of actual costs – a level that makes provision of services in the non-hospital setting very difficult if not prohibitive. RPA therefore strongly recommends that CMS pay the actual direct PE costs to provide a service. Second, CMS continues to include high cost supply items in the PE calculation. This creates a number of problems for providers in the non-hospital setting. The current methodology for updating prices of PE direct inputs using paid invoices works for most supplies but cannot be done frequently enough to accurately reflect the changes (increase or decrease) in price of high cost supplies. Additionally, providers are often hindered from using newer technologies with proven benefit because the costs of these devices are not reflected in the PE payment. 

An example of this affecting interventional nephrology is the use of covered stents for dialysis access procedures. A growing body of evidence is demonstrating the superiority of covered stents over bare metal stents in venous applications. Indeed, FDA approval has been obtained for covered stents in dialysis access but bare metal stent use remains for the most part “off label”. The PE payment for venous stent placement does not reflect this trend to the newer, higher cost stent device. Other examples of higher cost devices that may be coming in the near future for dialysis access include devices to create arteriovenous fistula anastomoses, devices to improve fistula cannulation, and technology to prevent development of neointimal hyperplasia within fistulae and grafts. In order to prevent a shift in procedures to the more expensive hospital setting, we recommend that CMS establish J-codes to separately pay for high cost supplies. The number of supply items that CMS has priced greater than $1,000 is relatively small and could be managed with annual updates to ensure the optimal technology is available for patients with appropriate payment for providers. 

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

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 be out of alignment in 2014. 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 2015 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 proposed to be 0.49, while the PE RVUs for CPT code 99232 are slated to be 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. Thus, the PE RVUs for inpatient dialysis will be less than that of its component code, and RPA believes that this is a rank-order anomaly that the Agency should correct administratively. 

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 signature
Rebecca Schmidt, DO 

Renal Physicians Association

1700 Rockville Pike
Suite 220
Rockville, MD 20852

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

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