On June 25, CMS posted “Medicare Program: Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2011”
(PDF LINK VERY LARGE FILE http://www.federalregister.gov/OFRUpload/OFRData/2010-15900_PI.pdf)
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)
- 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.