CMS comment period open now RE: physician payment for following home dialyzors

On June 25, CMS posted “Medicare Program: Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2011”
the relevant pages are 219 and 220 which I’ve pasted below in their entirety (except a table laying out the relevant codes which is attached, the last three codes in the table are the ones relevant to home dialysis)

[INDENT]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.


CMS will publish this in the Federal Register on July 13 but the comment period starts when they make it available, therefor, the 60-day comment period closes on August 24.

My take away is that CMS is proposing to require, for those dialyzing at home, the Monthly Capitation Payment (MCP) physician to provide at least one inperson patient visit per month to earn the MCP, effective January 1, 2011.

Right now your nephrologist is paid even for months that you, as a home patient, don’t get in to see them. This rule would require an office visit each month in order for MCP physicican to bill CMS.

It is definitely best practice to see your doc every month but I think there should be an exception. One thing to point out is that today the primary home hemo device, currently in use, is meant to be transportable so it should not be unexpected to have people out of the area for a prolonged period.

As an example a snowbird who splits their time between a home in the north and and in the south. Using NxStage they can remain a patient of the provider in the north while they are in the South - for months at a time. Another situation is if you live several hours away, a state away.

I think I should be able to assume the risk of less frequent visits. I’m interested in what you all think, one concern is that this could create another barrier to access if docs are worried about reimbursement.

I think this would apply to people on PD too - Dori maybe you can cross post?

Let’s see if Beth thinks so, and if so, I’ll do that.

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The proposed regulation does not specify any form of home dialysis, therefore this would apply to PD as well as home HD.

The Condition for Patient plan of care at 494.90(b)(4) already states:
I The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis.[/I]

The Interpretive Guidance at V560 for the above regulation text states:
[I]This requirement is to ensure that patients see a medical practitioner (i.e., physician, advanced practice registered nurse or physician assistant) at least monthly. The patient may see the practitioner in the dialysis facility (before, during or after treatment), or in the physician’s office if the record of care for that visit is incorporated into the dialysis facility medical record.

“Periodically while the hemodialysis patient is receiving in-facility dialysis” is meant to refer to in-center patients and should generally result in at least quarterly practitioner visits at the dialysis center during dialysis treatment. By periodically visiting the patient in the dialysis facility, the physician has an opportunity to assess the patient’s response to treatment and to observe the team care.

At a minimum, monthly medical progress notes should document that a physician or that a non-physician practitioner (i.e., advanced practice registered nurse or physician assistant) who functions in lieu of the physician, has seen each patient and addressed the status and plan for that patient’s renal and active comorbid problems.

This requirement applies equally to home patients, who are expected to receive equivalent care to in-center patients. A monthly visit is required for each home patient by either a physician, an advanced practice registered nurse, or a physician assistant. This visit may be conducted in the dialysis facility, at the physician’s office, or in the patient’s home.

Any patient may choose not to be seen by a physician every month. However, if there is a pattern of a patient consistently missing physician visits, the IDT should determine whether or not the patient is unstable according to these regulations, and should address the lack of medical oversight with the patient in the plan of care. [/I]

How the proposed change will impact the quality of care that home patients receive and whether the potential loss of reimbursement if every home dialysis patient is not seen monthly presents itself as a barrier to referring patients to home dialysis is yet to be seen. It’s also possible that requiring patients to be seen monthly for the physician to receive payment could also effectively eliminate the patient’s right to choose not to come to clinic and may result in physicians “firing” patients, which could limit their access to home dialysis.

One of Bill’s concerns is addressed in part (not the MCP reimbursement to the physician) in the ESRD Frequently Asked Questions Version 1.1 which states in relation to patients living remotely from the dialysis facility:

The POC would need to address specific hardships that home patients located in remote areas might have in being able to see their physicians on a monthly basis. The expectation is that a member of the medical team of the dialysis facility provides routine care including monthly visits. However, in some limited instances, a remotely located home patient may be seen by a primary care physician.

Should there be an exception for remote patients? How would “remote” be defined – distance from the dialysis facility; status of roads, especially in snow and ice; lack of available transportation, etc.? Would seeing a primary care physician locally still be allowed under the revised MCP without the treating physician losing payment for any month that he/she does not see the “remote” patient face-to-face?

In-center patients who travel have facilities and physicians at their destination that provide dialysis and physician supervision of their care and bill for it while they’re away from their home facility. Do home dialysis training clinics already provide medical records on traveling home patients to the patient and to back up facilities about traveling patients who will in their area longer than a month so patients can have a face-to-face visit with a physician or advanced practice RN or PA monthly and get labs drawn to make sure they are not becoming unstable? If a medical staff in the travel destination sees the patient once during the month, should he/she receive the MCP for the month(s) that the patient is in his/her area?

What protection is there to prevent a physician who wants to get full MCP reimbursement from terminating his/her relationship with a patient who doesn’t come for one or more months even with a valid reason? This could be an access to care issue if no other physician at the facility is willing to accept the patient and he/she has no orders for home dialysis equipment and supplies. In this case, the facility would also be unable to treat the patient and would have to follow the involuntary discharge procedure which includes trying to find another facility that would accept the patient. For remote patients, this might mean that they would only be able to get in-center dialysis or travel even farther.

I’m sure these are only a few of the issues that might arise as a result of this proposed change in reimbursement policy.

Incidentally, documents to help ESRD surveyors do their job, including the Interpretive Guidance can be found at:

Basically, I see the kidney specialist, now, once a month. Honestly, I really do not need once a month, medically. However, the nephrologist thinks it is a good idea and I trust his judgement. Yet, if I went out of town, the nephrologist said just to find a specialist in that area, no big deal.