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RPA Comments on 2016 Medicare Fee Schedule Final Rule

Creation/Revision Date: December 29, 2015

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December 29, 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-FC: 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 

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 other 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. 

As noted in our comments on the proposed rule, RPA firmly believes that the absence of the patient’s home or the dialysis facility from the list of approved sites for telehealth services vastly reduces the opportunities for home dialysis services to be furnished via telehealth means and thus, substantially limits the potential positive impact of this change. This policy constraint is particularly disadvantageous for home dialysis patients in rural areas who may live several hours’ drive from the nearest originating site. Also, where there is no opportunity for telehealth services, rural patients may be disinclined to choose home dialysis as their modality. Further, the exclusion of the home as an originating site compromises the nephrologists’ ability to evaluate the home dialysis patient as they routinely dialyze in their home environment as well as to meaningfully assess any potential impact of the environment on the patient’s wellbeing 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 significantly curtails the potential benefit of such a policy revision for individuals with kidney failure. 

Active Status Designation of Advance Care Planning Codes

RPA commends CMS for finalizing the proposal to transition the advance care planning (ACP) codes (CPT codes 99497-99498) from the “I” status (Not valid for Medicare purposes) 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 care of kidney disease, and will foster care that is compassionate and respectful of patient’s wishes for their own care. 

We also believe that the Agency’s 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 is a significantly positive step. 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 will likely contribute to great progress 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 final rule, the PE RVUs for CPT code 90935 (inpatient hemodialysis, single evaluation, which serves as the anchor for the inpatient dialysis code family) are set at 0.48, while the PE RVUs for CPT code 99232 are 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. 

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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