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RPA Comments on the 2014 Medicare Fee Schedule Proposed Rule

Creation/Revision Date: September 06, 2013

September 6, 2013 

Marilyn B. Tavenner, Administrator 
Centers for Medicare and Medicaid Services 
Department of Health and Human Services 
Attention: CMS-1600-P 
P.O. Box 8013 
Baltimore, MD 21244-8016 

Re: CMS-1600-P: Proposed Rule for Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2014 

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 renal disease. We are writing to provide comments on selected portions of the 2014 Medicare Fee Schedule Final Rule. 

RPA’s comments will focus on the following issues: 

• CMS’ Proposal to Use HOPPS and ASC Rates in Developing Practice Expense RVUs 

• Aggregate Impact of Proposed Rule on Interventional Nephrology Services and Vascular Access Care 

• Ongoing Reduction of Relativity Between Inpatient Dialysis Services and Associated Evaluation and Management Services

CMS’ Proposal to Use HOPPS and ASC Rates in Developing Practice Expense RVUs 

In the proposed rule, CMS notes that for some services, the non-facility fee schedule payment rates for procedures exceed those for the same procedure when furnished in an outpatient department (OPD) or an ambulatory surgical center (ASC). The Agency believes this is not the result of appropriate payment differentials between the services furnished in different settings, but rather that it is due to anomalies in the data used under the fee schedule and in the application of the resource-based PE methodology to the particular services. The rule goes on to express CMS’ belief that the hospital outpatient prospective payment system (HOPPS) data inputs are more accurate and validated because they are auditable and updated every year (as opposed to the fee schedule inputs that are updated, on a rotating basis, every few years). In an effort to improve the accuracy of fee schedule’s non-facility payment rates for each calendar year, the Agency proposes to use that current year’s HOPPS or ASC practice expense data (whichever is less) as a point of comparison in establishing PE RVUs for services under the fee schedule. 

RPA believes that his proposal is problematic in several ways. First, we simply disagree with the underlying premise that the HOPPS and ASC inputs are more accurate than those currently utilized in the fee schedule. As CMS knows, the fee schedule inputs are determined as part of the AMA’s Relative Value Update Committee (RUC) process, and due in no small part to the budget neutral orientation of the RUC process, these inputs undergo an intensive degree of scrutiny before they are included in a RUC recommendation to CMS and considered by the Agency. To the extent that the inputs are based on invoices for equipment and supplies, the value for these cost components are based on real invoices from real suppliers and are often subject to competitive marketplace forces which will only serve to reduce the costs of these services. In contrast, the HOPPS and ASC values are determined by the ambulatory payment classification (APC) process, based on hospital indication of cost. Given the absence of transparency affecting hospital costs, we see no evidence that the HOPPS and ASC data inputs are more accurate than those used in the fee schedule, as CMS asserts. 

Our second major concern with this proposal is based on this absence of transparency. In our review, it is not clear what the actual inputs are in the APCs, and there is no rationale for the differences in the costs reported by hospitals to be used in comparison with RUC recommended inputs, yet CMS depends heavily on those reported costs. RPA concurs with the recommendations of ACP and others that CMS employ greater transparency before proceeding to any implementation of this proposal; the Agency must show the APC direct PE inputs that it used in making comparisons across settings. Further, we urge CMS to release these data prior to the release of the final rule and upon release of future proposed and final rules. Without providing such data, the Agency has not met the requirements of the Administrative Procedure Act because it has issued a proposed rule without sufficient detail to permit meaningful and informed comment. 

Additionally, we are concerned about the impact of this proposal on specific fee schedule services. In our reading of the proposed rule, this provision alone would reduce the RVUs for CPT code 36147 (angiogram of dialysis access, a service commonly provided by interventional nephrologists) by an exceptionally large 33%. A diagnostic angiogram is critically important in evaluating and treating both dysfunctional and thrombosed dialysis accesses – native arteriovenous fistulae and grafts. Nearly 90% of patients currently on hemodialysis have one of these types of permanent access and may require angiography in the course of their management. It is RPA’s opinion that any proposal that reduces reimbursement by such a magnitude for a service of such clinical importance should be vetted as thoroughly as possible before implementation. 

Finally, CMS notes in the rule that: 

“A wide range of stakeholders and public commenters have pointed to the non-facility setting as the most cost-effective location for services. Given the significantly higher cost structure of facilities (as discussed above), we believe this is accurate.” 

In light of the fact that the Agency itself shares the belief that under the current pricing structure the non-facility setting is the most cost-effective location for services, we question why CMS would propose revisions that almost certainly will drive the provision of these services into less cost-effective settings, and urge CMS to reconsider this proposal. . 

RPA urges CMS to delay implementation of the proposal to cap certain non-facility practice expense values until issues related to the accuracy and transparency of the values, and overall cost-efficiency of the affected services, can be resolved. 

Aggregate Impact of Proposed Rule on Interventional Nephrology Services and Vascular Access Care 

RPA maintains its concern about the impact of fee schedule rulemaking in recent years on the discipline of interventional nephrology. In addition to the proposed reduction noted above for CPT code 36147, two additional vascular access services commonly provided to dialysis patients, CPT codes 35475 (Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel) and 35476 (Transluminal balloon angioplasty, percutaneous; venous) would experience total RVU reductions in excess of 9% in 2014 as proposed. These reductions are in addition to substantial reductions implemented for the current (2013) fee schedule, which were approximately 28% for 35475 and 15% for 35476. The 2013 reductions resulted in part from CMS’ decision to select an inappropriate comparator code on which to base work RVUs, one different from that recommended by the AMA’s Relative Value Update Committee (RUC). If the 2014 proposed values are implemented, the total RVUs for three services critically important to the vascular access care required by beneficiaries with kidney failure would be significantly reduced - over the course of two rulemaking cycles - by approximately 33% (CPT code 36147), 37% (CPT code 35475), and 24% (CPT code 35476). 

It is critically important for chronic kidney disease (CKD) patients to have such procedures performed in a timely manner, so as not to disrupt the patient’s dialysis treatment schedule and to be consistent with Medicare’s clinical requirements associated with the provision of dialysis. This aspect of care is greatly enhanced when services are delivered in non-facility settings, such as vascular access centers, which are more focused and responsive to the needs of CKD patients, in general, than hospital outpatient departments. Given these severe reductions, we are concerned that the vascular access care provided by interventional nephrologists in non-facility settings would be at risk, and may be shifted to outpatient departments, compromising beneficiary access to timely care, an important aspect of the quality of care for those on dialysis. 

RPA urges CMS to consider the aggregate impact of recent changes on the discipline of interventional nephrology and vascular access care in general before finalizing the proposals outlined in the proposed rule. 

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 2013. 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 2014 fee schedule, the PE RVUs for CPT code 90935 (inpatient hemodialysis, single evaluation, which serves as the anchor for the inpatient dialysis code family) will be 0.50, while the PE RVUs for CPT code 99232 will 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. 

RPA therefore urges CMS to revise the practice expense values for the inpatient dialysis code family to ensure that they are not less than that of its component codes.

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

Thank you, 

Kossmann signature 2

Robert J. Kossmann, MD 

Renal Physicians Association

1700 Rockville Pike
Suite 220
Rockville, MD 20852

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

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