Nephrology practices will not see much difference in outpatient dialysis payments from Medicare in 2020, but changes to the program’s merit-based incentive payment system and a change in how acute kidney injury care is covered may have an impact in 2021 and beyond, according to an analysis by the Renal Physicians Association.
CMS issued a final rule earlier this month on its Physician Fee Schedule. Comments on the final rule are due Dec. 31.
The final rule included some positive news for nephrologists, Robert Blaser, director of public policy for the Renal Physicians Association, wrote in an analysis for RPA members.
“ ... CMS finalized its proposals to allow for billing of transitional care management (TCM) codes for monthly dialysis patients and to update the structure and valuation of evaluation and management (E&M) services,” Blaser wrote. “In addition, payment for all dialysis codes is incrementally increased.” Increases will be between 0.1% and 1%, but for CPT code 90970, which covers payments for adult daily dialysis, there is an increase of 4.5%.
“For CPT code 90960, the adult in-center, four-visit code, the increase is 0.8%, which with the increase in the conversion factor works out to a $2.21 increase (unadjusted for geography), while CPT code 90935 (hemodialysis, single evaluation) is increased by 0.4%, working out to a $0.32 bump,” Blaser wrote in his analysis. “Regarding the dialysis circuit codes for interventional dialysis services, the two high volume codes, CPT codes 36902 (angioplasty) and CPT code 36905 (thrombectomy with angioplasty), experience 2.5% and 3.% increases when these services are provided in the physician-office setting.”
Along with other medical society groups, the RPA signed a letter sent Nov. 21 to members of Congress expressing support for updates to the E&M codes, which govern payment for physician office visits.
“ ... [The] Medicare program made a strong inroad toward addressing the historic undervaluation of Evaluation and Management (E/M) codes (office visits) by internal medicine specialists and other physicians who deliver primary and subspecialty care to millions of Medicare patients,” according to the letter. “ ... Studies show that access to primary care physicians and cognitive specialists is associated with better outcomes, increased longevity, lower costs, and reduced preventable hospital and emergency room admissions. Internal medicine subspecialists also provide a critically important role in the diagnosis, care and treatment of patients with serious acute and chronic illnesses, in coordination with primary care physicians, resulting in better outcomes and reduced costs associated with preventing unnecessary hospital admissions, re-admissions, and complications.”
In the final rule, CMS is changing the methods for documenting E&M services and payment will be determined by either medical decision-making or time; patient history and physical documentation “only needs to reflect what is medically appropriate,” Blaser wrote, and total time, including time spent by the practitioner on the day of the visit (face-to-face and non-face-to-face time) can be billable.
The conversion factor for 2020 was finalized “at the proposed level of $36.09, a $0.05 increase over the $36.04 CF for 2019,” Blaser wrote, and, importantly, CMS abandoned its plans to restructure E&M coding outlined in the 2019 fee schedule proposed rule that would have collapsed payment amounts for the higher-level codes into a single level.
“This decision sustains a huge victory for cognitive care in general, although it appears that the specialty specific impact of the change for nephrology is -2%,” Blaser wrote. “While this impact is unexpected, it should be considered in the context of the cuts expected out of last year’s proposed rule (approximately 13%) and is only a projection.”
CMS also finalized its proposals regarding physician supervision requirements for physician assistants (PAs) and review of notes by medical students.
Changes to MIPS
In negative news for nephrologists, the final rule includes the elimination of nephrology-specific performance measures for the merit-based incentive payment system (MIPS). CMS is also implementing an episode-based quality measure for acute kidney injury requiring new inpatient dialysis. RPA opposed both proposals in its comments on the proposed rule, Blaser wrote.
RPA comments on the MIPS quality component of the proposed rule “highlighted our concern that the rate at which such changes are being proposed and implemented is counter to CMS’ own goals,” Blaser wrote in his analysis. “RPA stated that the [quality payment program] QPP must be allowed to mature, and dramatic changes as proposed with the elimination of specialty-specific measures and the development of the MIPS value pathways (MVPs) are premature. Furthermore, continually changing the program has increased provider burden, and potentially burnout, by requiring time away from patients to study changes and implement new workflows, rather than allowing providers the space to understand and comply with the existing components of the QPP.”
In comments on the proposed rule to CMS Administrator Seema Verma, RPA President Jeffrey A. Perlmutter, MD, wrote, “RPA believes that MIPS quality measures should be relevant to the daily care provided by providers and that the move to primary care-centric measures is detrimental to the care of the nation’s kidney patients. To advance the quality of care for patients with kidney disease, it is critical that nephrologists are measured by specific, relevant, and clinically meaningful measures.”
Measures that were removed covered pediatric patients receiving dialysis with hemoglobin levels less than 10 g/dL; catheter use at initiation of hemodialysis; catheter use greater than or equal to 90 days; preventive care and screening for influenza immunization; and referring adult patients on dialysis to hospice.
Disclosures: Blaser is the Director of Public Policy for the Renal Physicians Association.