Creation/Revision Date: July 08, 2015
July 8, 2015
Patrick Conway, M.D.
Principal Deputy Administrator
Centers for Medicare and Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244
Re: Planned Revision of the ESRD Medical Evidence Report (Form 2728)
Dear Dr. Conway,
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 address CMS’ plans to update the end-stage renal disease (ESRD) Medical Evidence Report (Form 2728) in advance of the transition to the ICD-10 diagnosis coding system on October 1, 2015.
To begin, RPA completely concurs with the recommendation of Kidney Care Partners (KCP) that CMS seek input from kidney community stakeholder groups as the revision of the 2728 form is being pursued via a 30-day public comment period, and that this solicitation could be achieved by a sub-regulatory input solicitation process without going through full Federal Register notice-and-comment rulemaking. Albeit with less urgency, as you know CMS recently utilized such a process to solicit input on the ESRD Facility Conditions for Coverage, and it is our understanding that the kidney community was responsive to the Agency’s request.
Specific to the draft 2728 form itself, it includes far too many diagnosis codes, many of which are peripheral but more often clearly are not indicative of the cause of ESRD. Acknowledging that the shift to ICD-10 will inherently involve the use of more diagnosis codes in general, this is likely to be less true in kidney disease and nephrology than other disease states and specialties, and the inclusion of so many superfluous diagnosis codes on the 2728 serves little purpose.
It is worth noting that Question 15 on the 2728 form asks for the “Primary Cause of Renal Failure”, and instructs the physician completing the form to use the “code” from the back of the form, not the “codes” from the back of the form. Similarly, the form does not require complete coding of the patient’s condition (in the sense that typical coding convention calls for coding to the greatest degree of specificity), but again, just asks for the primary cause of renal failure.
Regarding the draft list of codes itself, RPA believes that a preponderance of the codes we consider to be superfluous fall into five categories: (1) codes that lack sufficient specificity to be used on this form or to have downstream benefit in the context of data gathering (such as any code, usually ending in ‘9, that uses the terms “other” or “unspecified”); (2) codes for conditions that occur too rarely in kidney disease to merit being included on the 2728 (such as T56.0X2A—Toxic effect of lead and its compounds, intentional self-harm, initial encounter); (3) codes for conditions that are caused by ESRD, not the cause of ESRD (such as the M10.3 series of gout codes); (4) codes that are completely unrelated to kidney disease (such as T86.43, liver transplant infection) and (5) codes that are multiplicative by virtue of citing many types of organ involvement or different limbs or body parts (such as M1A.1710, lead induced chronic gout, right ankle and foot, without tophus [tophi]). RPA is concerned that the inclusion of a vast number of unnecessary ICD-10 codes on the 2728 form will: (1) render the form virtually unworkable at the point of contact for the nephrologist; (2) increase the volume of errors made by administrative personnel entering the data into the ESRD CROWNweb system; and (3) generate a large amount of data that is not meaningful for purposes in which that data is subsequently used.
For these reasons, RPA strongly urges CMS to:
1. Seek kidney community on the revision of the ESRD Medical Evidence Report (Form 2728); and
2. Substantially reduce the number of diagnosis codes appearing on the 2728 form.
Appended to this document is a desk-side reference guide to kidney disease ICD-10 coding that RPA developed for use by coding and billing personnel in nephrology practices. While this document does include some ICD-10 codes that wouldn’t be appropriate for inclusion on the 2728 form (such as those for chronic kidney disease—CKD—stages 1-4), it does include what we believe to be a list of the diagnosis codes that would account for the vast majority of the conditions that are the primary cause of ESRD. Given that nephrology coding and billing expertise is among the core competencies of RPA, we would welcome the opportunity to assist the Agency in further refining the list of ICD-10 codes that appear on the 2728 form.
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 email@example.com.
Rebecca Schmidt, DO
cc: Laurence Wilson, Director, Chronic Care Policy Group
Jana Lindquist, Director, Division of Chronic Care Management
Shari M. Ling, M.D., Deputy Chief Medical Officer, Center for Clinical Standards and Quality