Barriers & Tips to Overcome Them

What barriers have you encountered starting and keeping a PD program running that you have overcome and how did you overcome them? :?:

The biggest barrier that I’ve faced is doctors not getting much experience with PD in their fellowship training and being reluctant to refer good PD candidates for PD. I’ve told new nephrologists that I have lots of experience with PD and if they send me their patients, by teaching the patients well and supporting them to do as much as they can, it will take a lot of pressure off them that they usually have taking care of in-center hemo patients. This has worked really well. In fact, one of our newest nephrologists is now my biggest referral source.

Hi all,

I agree with PD Nurse that one issue is not enough fellow exposure to PD during training. Does anyone have any ideas for how to incorporate more PD and other home dialysis into Fellowship programs? Are there folks around the U.S. who are doing a great job of this and have best practices to share?

Patients have a right to be able to access all of the modalities, so it’s important for us to figure out ways to address these barriers…

A key element in getting fellows trained in PD is having attending Nephrologist who are interested in chronic dialysis and especially PD. The program I work in receives all of its referrals from a teaching hospital. Years ago there were several Nephrologists there who did an excellent job of training fellows and referring patients for PD, then they left. For the past few years, the attendings at this teaching hospital have been focused on other areas of Nephrology and our referrals for PD have dropped - a lot. With new Nephrologists entering the system that do have an interest in chronic dialysis and PD we are hoping to begin to see a rise in our patient population and fellows who are getting more PD experience.

I wonder if there is a way to create incentives in the system somewhere for including PD training in nephrology fellowship programs, or even for referring appropriate patients to PD…

It would be great if the federal government came up with incentives to encourage physicians to refer patients to home dialysis. The only financial incentive that physicians get for home patients is $500 each time a new patient is trained to do self-care (any kind – PD or hemodialysis at home or in a Medicare approved self-care program). Nephrologists are paid a monthly fee to be on-call and supervise the care of dialysis patients. Recently Medicare changed how it pays MDs and nephrologists that have home patients get less than if they follow a center patient that they (or their partner or a nurse practioner) see 4 times a month.

Even though it costs Medicare less for PD patients than for in-center hemo patients each year, a physician is paid at a higher rate when a patient is hospitalized than he/she gets when the patient is healthy. Medicare pays physicians a set amount for monthly follow-up of center or home dialysis patients. If a patient is hospitalized, the doctor subtracts the number of days a patient is hospitalized to calculate what can be billed for outpatient follow-up and bills a different rate for those days the patient is in the hospital.

FYI – Patients are rewarded for doing self-care (home or in a Medicare approved self-care program) by getting Medicare from the first day of the month dialysis starts rather than having to wait 3 months for Medicare. This may not make much difference for a patient who has good health insurance, but it can make a tremendous difference for a patient who has no or limited health insurance.

Hi Beth,
I have been employed by this medical center for 13 yrs. I had 10 yrs of experience when I came here. I have told the billing folks here about the 500 dollar training fee they can bill for and they simply say " we don’t do that here." I think perhaps they mean - we don’t know how to do that here. Can you enlighten me as to what the medicare billing code is to be paid for this. We are a hospital based unit and are constantly being told we operate at a loss. Seems like this would help.

The billing codes for the training fee is CPT-90989 for completed training and 90993 per day for patients that do not complete training. Being in hospital might have some effect on your ability to code for the training. I’m not sure if you have to be a free standing clinic asa outside the hospital to be able to bill for the training. I might call your network or CMS to get a proper explanation on this topic.

What do you think is the best approach to use to convince doctors and nurses to consider and refer patients for PD?