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RPA Comments on 2016 Medicare Fee Schedule Proposed Rule

Creation/Revision Date: September 08, 2015

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September 8, 2015 

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-1631-P: Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2016 

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 2016 Medicare Physician Fee Schedule Final Rule. 

RPA’s comments focus on the following issues: 

• Addition of Home Dialysis Codes to Telehealth Service List 
• Active Status Designation of Advance Care Planning Codes 
• Ongoing Reduction of Relativity Between Inpatient Dialysis Services and Associated Evaluation and Management Services 
• Valuation of Collaborative Care Activities in the MFS 
• PQRS Measures Pertaining to Kidney Care 

Addition of Home Dialysis Codes to Telehealth Service List 

RPA appreciates CMS’ proposal to add the CPT codes for home dialysis services (Codes 90963-90966) to the list of category 1 telehealth services for 2016. We concur that home dialysis services are sufficiently similar to psychiatric diagnostic procedures or office/ outpatient visits currently on the telehealth list to qualify on a category 1 basis, and believe that this proposal is a modest step toward expanding the use of home dialysis modalities. 

However, we do not agree with the Agency’s following statement in the proposed rule: 

“Although these services are for home-based dialysis, and a patient’s home is not an authorized originating site for telehealth…many components of these services would be furnished from an authorized originating site and, therefore, can be furnished via telehealth.” 

RPA firmly believes that an originating site policy that does not include the patient’s home (or the dialysis facility for that matter) vastly reduces the opportunities for home dialysis services to be furnished via telehealth means. This policy constraint is highly disadvantageous for home dialysis patients in rural areas who may live several hour’s drive from the nearest originating site, and thus reduces the likelihood that telehealth will be the chosen modality for some patients. Further, the exclusion of the home as an originating site compromises the nephrologists’ ability to evaluate the home dialysis patient in the environment in which they are doing the dialysis procedure so as to be able to meaningfully assess any potential impact of that environment on their well being during the dialysis process. 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 substantially curtails the potential benefit of such a policy revision. 

Active Status Designation of Advance Care Planning Codes 

RPA is strongly supportive of CMS’ proposal to transition the advance care planning (ACP) codes (CPT codes 99497-99498) from the “I” status (Not valid for Medicare purposes. Medicare uses another code for the reporting and payment of these services) to the “A” (Active) status. We believe that these codes will be quite useful in promoting the use of advance care planning and advance directives, particularly in the treatment of kidney disease, and will foster care that is compassionate and respectful of patient’s wishes for their own care. 

Further, we commend the Agency for the decision to allow these services to be used in conjunction with the monthly capitated payment (MCP) codes for services provided to end-stage renal disease (ESRD) patients. We believe the importance of fostering the ability of dialysis patients and their nephrologists to have discussions regarding the future of their care cannot be overestimated. This is a great step forward in the care of ESRD patients and we appreciate and are encouraged by CMS’ action in this area. 

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 2016. 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 2016 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 0.48, while the PE RVUs for CPT code 99232 are slated to be 0.55, 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. 

Valuation of Collaborative Care Activities in the MFS 

RPA is greatly encouraged by CMS’ movement in recent fee schedule cycles to expand Medicare reimbursement for care management services and non face-to-face activities, as we believe that these services have been provided by primary care physicians and cognitive-based subspecialists such as nephrologists for years without meaningful reimbursement. 

In response to some of the specific questions that the Agency poses in the NPRM on structuring collaborative care services, RPA believes that it would be a reasonable first step to tie those inter-professional care activities to specific beneficiary encounters, as another E&M service would be a likely catalyst for care collaboration to occur, and to perhaps utilize the concept of an add-on code to structure and value the collaborative care service. With regard to beneficiary protections, RPA also believes that it would be reasonable to require documentation indicating that the patient has been advised that collaboration between physician is occurring, and we support the comments by the Evaluation and Management Coalition that patient financial liability be waived for all collaborative care services, as increasing access to specialty knowledge and to decision support is highly likely to improve patient care. 

Specific to kidney disease care, we strongly urge CMS to allow the future service codes to be developed for collaborative care activities to be billed in conjunction with the ESRD MCP for the general non renal-related (non-dialysis) evaluation and management of dialysis patients. Not only do nephrologists often serve as the de facto primary care physician for many of their dialysis patients (as non-renal related care is routinely required in the care of ESRD patients who typically have many other chronic diseases, the problems for which they tend to bring with them to dialysis for evaluation), but non renal-related care is specifically excluded from the ESRD MCP Scope of Services, as outlined in the 1996 Medicare fee Schedule Final Rule. RPA steadfastly believes that allowing nephrologists the ability to bill for these non-ESRD services for their ESRD MCP patients will not only greatly enhance the care coordination and ultimately the overall quality of care for Medicare beneficiaries with ESRD, but it would also increase the likelihood of care being provided for their non-related issues in a patient-centered, integrated, and holistic manner. 

PQRS Measures Pertaining to Kidney Care

RPA strongly disagrees with the proposal to remove the following two quality measures related to ESRD from the Physicians Quality Reporting System (PQRS). 

• PQRS 81: Adult Kidney Disease: Hemodialysis Adequacy: Solute: Percentage of calendar months within a 12 month period during which patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis three times a week for ≥ 90 days who have a spKt/V ≥ 1.2. 

• PQRS 82: Adult Kidney Disease: Peritoneal Dialysis Adequacy: Solute: Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving peritoneal dialysis who have a total Kt/V ≥ 1.7 per week measured once every 4 months. NOTE: This measure was reviewed by the National Quality Forum (NQF) Renal Standing Committee in May 2015 and it was recommended for continued endorsement. Per USRDS Annual Data Report 2014: Achievement of the KDOQI adequacy target for peritoneal dialysis (PD) of a weekly Kt/V ≥1.7 is 87 percent, indicating that a performance gap remains. 

Adequate dialysis dose is strongly associated with better outcomes, including decreased mortality, fewer hospitalizations, fewer days in the hospital, and decreased hospital costs. Further, there are currently very few measures upon which nephrologists can be evaluated for their ESRD patients (who for many nephrologists represent a substantial majority of the ESRD patient census), thus creating a barrier to their participation in the PQRS program, and the peritoneal dialysis measure was only recently recommended for continued endorsement by the NQF. RPA therefore strongly urges CMS to retain these measures in the PQRS program. 

RPA does support the addition of the following measure on hospice referral to PQRS. 

• Adult Kidney Disease: Referral to Hospice: Percentage of patients aged 18 years and older with a diagnosis of end-stage renal disease (ESRD) who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care. 

We believe adoption of this measure fits hand-in-glove with the CMS proposal to make active the CPT codes for advance care planning (codes 99497-99498) addressed above, and will not only provide CMS with a means to track the appropriate use of hospice services provided to ESRD patients, but will also incent nephrologists to consider the appropriate use of hospice services given the use of the measure in the PQRS 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 rblaser@renalmd.org. 

Sincerely, 
Rebecca Schmidt DO signature
Rebecca Schmidt, DO 
President 

Renal Physicians Association

1700 Rockville Pike
Suite 220
Rockville, MD 20852

Phone: 301-468-3515
Fax: 301-468-3511
Email: rpa@renalmd.org

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