CMS Proposes Strict Physician Visit Requirement for Home Dialyzors

By Bill Peckham

Right now there is a comment period for a proposed rule having to do with Medicare payments called: Medicare Program: Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B (for CY 2011) (Document ID CMS-2010-0205). This is another giant 671 page proposed rule (PDF link), this one covers Medicare payments to physicians under Part B. 

There doesn't seem to be any submitted comments, even though the 30 day comment period closes August 24th so maybe it's not very controversial. There's a lot in there and I can't say I've reviewed the whole thing but I have looked at one section that was brought to my attention. 

On Pages 62 to 64 there is a section that refers to nephrologists providing care to people on home dialysis:

C. End-Stage Renal Disease Related Services for Home Dialysis 
(CPT Codes 90963, 90964, 90965, and 90966)

1. End-Stage Renal Disease Home Dialysis Monthly Capitation Payment Services
(CPT Codes 90963, 90964, 90965, and 90966) 

In the CY 2004 PFS final rule with comment period (68 FR 63216), we established new Level II HCPCS G-codes for end-stage renal disease (ESRD) monthly capitation payment (MCP) services. For center-based patients, payment for the G-codes varied based on the age of the beneficiary and the number of face-to-face visits furnished each month (for example, 1 visit, 2–3 visits and 4 or more visits). Under the MCP methodology, the lowest payment applied when a physician provided one visit per month; a higher payment was provided for two to three visits per month. To receive the highest payment, a physician would have to provide at least four ESRD-related visits per month. However, payment for home dialysis MCP services only varied by the age of beneficiary. Although we did not initially specify a frequency of required visits for home dialysis MCP services, we stated that we ‘‘expect physicians to provide clinically appropriate care to manage the home dialysis patient’’ (68 FR 63219). 

Effective January 1, 2009, the CPT Editorial Panel created new CPT codes to replace the G-codes for monthly ESRD-related services, and we accepted the new codes for use under the PFS in CY 2009. The CPT codes for monthly ESRD-related services for home dialysis patients include the following, as displayed in Table 32: 90963, 90964, 90965, and 90966. In addition, the clinical vignettes used for the valuation of CPT codes 90963, 90964, 90965, and 90966 include scheduled (and unscheduled) examinations of the ESRD patient. 

Given that we pay for a physician (or practitioner) to evaluate the ESRD patient over the course of an entire month under the MCP, we believe that it is clinically appropriate for the physician (or practitioner) to have at least one in-person, face-to-face encounter with the patient per month. Therefore, we are proposing to require the MCP physician (or practitioner) to furnish at least one in-person patient visit per month for home dialysis MCP services (as described by CPT codes 90963 through 90966). This requirement would be effective for home dialysis MCP services beginning January 1, 2011. We believe this requirement reflects appropriate, high quality medical care for ESRD patients being dialyzed at home and generally would be consistent with the current standards of medical practice. 

2. Daily and Monthly ESRD–Related Services
(CPT Codes 90951 through 90970) 

In CY 2008, the AMA RUC submitted recommendations for valuing the new CY 2009 CPT codes displayed in Table 32 that replaced the MCP HCPCS Gcodes for monthly ESRD-related services. We accepted these codes for use under the PFS.

 

There are four additional CPT codes for ESRD-related services that are reported on a per-day basis. These daily CPT codes are: 90967 (End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age); 90968 (End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 2–11 years of age); 90969 (End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 12–19 years of age); and 90970 (End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 20 years of age and older). 

For the MCP codes displayed in Table 32, the AMA RUC initially recommended 36 minutes of clinical labor time for the pre-service period. They also recommended an additional 6 minutes in the post-period for CPT codes 90960, 90961, 90962, and 90966. For the four codes describing daily services (CPT codes 90967 through 90970), the AMA RUC recommended including 1.2 minutes of clinical labor per day, which is the prorated amount of pre-service clinical labor included in the monthly codes. The AMA RUC also recommended that CPT codes 90952 and 90953 be contractor-priced. 

In the CY 2009 PFS final rule with comment period (73 FR 69898), we asked the AMA RUC to reconsider their recommended PE inputs in the interest of making certain that they accurately reflected the typical direct PE resources required for these services. In addition, we asked the AMA RUC to review the physician times for CPT codes 90960 and 90961 that are used in the calculation of the PE RVUs. We accepted the work values for the new CPT codes for ESRD-related services that were recommended by the AMA RUC. 

Since CY 2009, we have continued to calculate the PE RVUs for the entire series of MCP codes displayed in Table 32 by using the direct PE inputs from the predecessor HCPCS G-codes, except for CPT codes 90952 and 90953 which are contractor-priced. We have also continued to use the physician time associated with the predecessor HCPCS G-codes for CPT codes 90960 and 90961 for purposes of calculating the PE RVUs. 

In CY 2009, the AMA RUC submitted new recommendations for CPT codes 90951 and 90954 through 90970. For each of the MCP codes (CPT code 90951 and CPT codes 90954 through 90966), the AMA RUC recommended an increased pre-service clinical staff time of 60 minutes. For each of the daily dialysis service codes (CPT codes 90967 through 90970), the AMA RUC recommended an increased clinical labor time of two minutes, which is the prorated amount of clinical labor included in the monthly codes. The AMA RUC also recommended an additional 38 minutes of physician time for CPT codes 90960 and 90961. This resulted in a total physician time of 128 minutes and 113 minutes, respectively, for these codes. The AMA RUC continued to recommend that CPT codes 90952 and 90953 be contractorpriced. 

For CY 2011, we are proposing to accept these AMA RUC recommendations as more accurate reflections of the typical direct PE resources required for these services. Therefore, we are proposing to develop the PE RVUs for CPT code 90951 and CPT codes 90954 through 90970 using the direct PE inputs as recommended by the AMA RUC and reflected in the proposed CY 2011 PE database, which is available on the CMS Web site under the supporting data files for the CY 2011 PFS proposed rule at: http:// www.cms.gov/PhysicianFeeSched/. We are also proposing to use the AMA RUCrecommended physician times for CPT codes 90960 and 90961. Consistent with the AMA RUC’s recommendations, we are proposing to continue to contractorprice CPT codes 90952 and 90953.

That's the whole home dialysis related section from the 632 page document but the part I have concerns about, and I think will submit a comment about, is the last paragraph of the first section (my emphasis):

Given that we pay for a physician (or practitioner) to evaluate the ESRD patient over the course of an entire month under the MCP, we believe that it is clinically appropriate for the physician (or practitioner) to have at least one in-person, face-to-face encounter with the patient per month. Therefore, we are proposing to require the MCP physician (or practitioner) to furnish at least one in-person patient visit per month for home dialysis MCP services (as described by CPT codes 90963 through 90966). This requirement would be effective for home dialysis MCP services beginning January 1, 2011. We believe this requirement reflects appropriate, high quality medical care for ESRD patients being dialyzed at home and generally would be consistent with the current standards of medical practice.

I agree with the statement that it is clinically appropriate for the physician to have at least one in-person, face-to-face encounter with the patient per month, however, I think there should be some flexibility built into the system. This rule is proposing that if I don't get into see my doc during the month he doesn't get paid, even while he attends to my care by reviewing labs, is available to the unit and to me whether or not I have gotten in to see him that month. 

My initial reaction is that there should be some patient autonomy, and that the physician must make themselves available for monthly, face to face office visits BUT the patient needs to have some flexibility. I'm worried that this will create a barrier to home dialysis, particularly among patients who can most benefit from dialysis at home, those that can thrive while combining home dialysis with a busy life. I'm worried about adding to the dialyzor burden that comes with home dialysis. A no exceptions policy does not sound optimal.

Thoughts? Comments are due by August 24th.

Comments

[Brian Sierk]

Posted comment:

"This comment is in regards to the mandated face to face monthly meeting with doctors and home dialyzors.
One of the many purposes of Home dialysis is the removal of barriers to an active life and mobility. This proposed rule precludes any sort of extended trip or out of state job assignment. I would encourage CMS to allow a patient initiated exception to this rule to facilitate this type of extended vacation or job posting that is theoretically possible with home hemodialysis and other forms of home dialysis. The other beneficiary of this would be the very active, significantly empowered dialyzor that is equipped and perhaps prefers to manage their dialysis and health with their physician online,

Another potential problem with the policy is likelihood that a physician would limit access to home dialysis due to the greater difficulty of scheduling a face to face meeting with a home dialysis patient. There needs to be clarity in the rule that home dialysis is a preferred modality for CMS patients, and that Physicians that are blocking access to home dialysis for this reason are not acting in the best interest of the patient."

Did I miss anything?

[Zach]

As one who has been on hemodialysis for over twenty-eight years and has a very active life/work, I have found it difficult to visit my nephrologist each and every month.

Tele-medicine might be the answer --either by phone or the internet.

[Jonathan]

Bill,
As always, I appreciate your well thought out response, and for the most part agree. I think monthly visits are wholly appropriate and should be required to some extent (by "required" I mean, if you miss one it should be for good reason). However, I don't like the thought of legislation making it possible for the neph. to be punished if the patient misses one of these monthly visits. I agree that flexibility needs to be built into the system, and there needs to be some mechanism to allow for very real situations which arise in which someone can't easily make it to their normal nephrologist within a given month.

[somerville]

When I was on home hemodialysis, I had to have one visit with a nephrologist every month plus two lab tests in the hospital. That meant that the 'increase in freedom' provided by home hemodialysis amounted to a reduction of monthly hospital visits from 12 to 3 per month, with an increase in dialysis sessions from 12 to 24 per month, plus 4 machine-cleaning days. Since the administrative inefficiency of hospital tests and nephrologist visits meant that a 15-minute test procedure or meeting would absorb about three hours of time, to say nothing of travel time back and forth, the gain of freedom in daily over in-center dialysis began to seem quite limited.

[George Kendall]

The Dr. visit each month is important to both patient and Dr. to keep a handle on what's going on with each individual, BUT there may be a month or so each year when the monthly appointment is not possible and/or inconvenient for the patient becasue of planned vacation, family obligations, illness, or any other numerous reasons. I would suggest an excused absence for at least one or two months a year. Home hemo dialysis is to allow a "more" normal life style as well as improved health/wellness. A restriction requiring 100% attentance for a monthly Dr. visit, especially when all is going well is being just too controling and restrictive.

[Rich Berkowitz]

Here's the comment I submitted to CMS. It's important that others send in their comments. We had over 1500 comments to the proposed rules on Bundling. At the time, we urged dialyzors to remain engaged. We said the public policy advocacy never ends. This is an example of why a dialyzor must keep her foot to the pedal. The QIP rules are another example. The comment period end on September 24th for that. Let's keep the ink flowing.

Re: Medicare Program: Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B (for CY 2011) (Document ID CMS-2010-0205) and more specifically End-Stage Renal Disease Related Services for Home Dialysis (CPT Codes 90963, 90964, 90965, and 90966) and End-Stage Renal Disease Home Dialysis Monthly Capitation Payment Services (CPT Codes 90963, 90964, 90965, and 90966)

I am a home dialyzor and have been doing it for over 4 ½ years. That means I have bought into the concept of self-care. But as much as I depend on myself, I also depend on the rest of my dialysis team. That team is headed up by my nephrologist. I’ve come to rely on him constantly, not just the one monthly appointment I have scheduled. During the month I will email him with questions about my treatments and issues that might crop up. I simply don’t wait for my clinic visit. That’s not how dialysis works. It’s not a once a month- face-to-face meeting. It’s an every day occurrence and critical to maintaining my life.

I’ve been with my nephrologist since 1998 when I had a radical nephectomy due to renal cell carcinoma. Immediately I had chronic kidney disease (CKD) because of my additional hypertensive condition I had since becoming an adult. My CKD progressed until I had to go on dialysis on 2003. At that time, my nephrologist told me about home hemodialysis. That’s what I decided to do. But there was a problem. Nobody in my area was offering it. He wanted the hospital to sponsor it and was hoping a program would be approved shortly. However, shortly it wasn’t. It took three years before the hospital approved just me for home hemodialysis. He fought touch and nail to get it approved. And by getting me on home hemodialysis, he saved my life.

Like many others doing in-center conventional hemodialysis (CHD), I was failing. The three treatments per week proved to not be enough to keep me healthy. After the 18 months of CHD, I suffered a heart attack driving home from a dialysis session. My cardiovascular system couldn’t handle the constant battle with the ups and downs of fluid imbalance. I was unable to remove as much fluid as I was in the beginning. If something didn’t change I would probably die.
My nephrologist doubled his efforts and urged me to get more involved in getting the hospital to allow me to do home hemodialysis. Eventually, after three years of CHD, with a fourth justified treatment added due to my medical condition, I got the word I was to start training for home hemodialysis. That changed my life! That saved my life! I could never thank my nephrologist enough for the role he’s played in my life.

I continue to be under his care. It’s different now because I am now the leader of my medical team. That’s what happens when one is successful with the home modality. I have learned so much about CKD5 since going home that I can now make recommendations to my nephrologist about my care and bounce ideas off of him. He became open to the idea of me changing for short daily treatments to nocturnal. This has even enhanced my life further. As much as I now know, I still need him.. And it’s not because CMS regulations say I need him.

I diligently see him every month, and he gets paid for that. The proposed rules stipulate he must see me once a month to get paid. But! But life happens. For various reasons, no fault to him, I might have to cancel an appointment. Perhaps it’s a family obligation that causes me to miss an appointment. It might be my wife and I go away for a vacation. Or I might be sick. Or I might even have been hospitalized for a couple of days. The point is that based upon the proposed rule, he wouldn’t get paid because he didn’t see me that one day, even though he may be following my care the remainder of the month.

I don’t believe it’s fair to penalize him for my actions. Remember, I’m still relying on him. Being a nephrologist is a full time job. He must be available to deal with an issue during the entire month and not just the half hour block he may have set up for me to see him. Yet, the rule predicates payment for that one short period of time. Never mind the rest of the time. For those reasons, I don’t think a hard and fast rule should be present. As it is right now, it is too arbitrary without exception. Maintaining a relationship with my nephrologist is essential to my well being. I don’t want to see anything get in its way. If he doesn’t get paid because I’ve missed the monthly appointment, that’s a reason for him not to be able to give me his full attention when I need it.

Please reconsider this part of the new rules. Perhaps more flexibility can be put in. Maybe documentation can be made available of other encounters during the month. Perhaps that would be sufficient to indicate his ongoing care on my behalf. My life depends on him continuing to get paid.

[Bill Peckham]

This document gives an overview of the situation as implemented. The bottom line:
In addition, documentation by the MCP physician (or practitioner) should support at least one face-to-face encounter per month with the home dialysis patient. However, Medicare contractors may waive the requirement for a monthly face-to-face visit for the home dialysis MCP service on a case by case basis; for example, when the nephrologists notes indicate that the physician actively and adequately managed the care of the home dialysis patient throughout the month.

[Bill Peckham]

Here is the relevant section from the Medicare Claims Processing Manual
Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims (PDF LINK)(emphasis added):

140.1.1 - Payment for Managing Patients on Home Dialysis
(Rev. 1999, Issued: 07-09-10, Effective: 01-01-11, Implementation: 01-03-11)

Physicians and practitioners managing ESRD patients who dialyze at home are paid a single monthly rate based on the age of the beneficiary. The MCP physician (or practitioner) must furnish at least one face-to-face patient visit per month for the home dialysis MCP service. Documentation by the MCP physician (or practitioner) should support at least one face-to-face encounter per month with the home dialysis patient. Medicare contractors may waive the requirement for a monthly face-to-face visit for the home dialysis MCP service on a case by case basis, for example, when the nephrologist’s notes indicate that the physician actively and adequately managed the care of the home dialysis patient throughout the month. The management of home dialysis patients who remain a home dialysis patient the entire month should be coded using the ESRD-related services for home dialysis patients HCPCS codes.