2013 Medicare Fee Schedule Final Rule Impact on Nephrology ...

<strong>2013</strong> <strong>Medicare</strong> <strong>Fee</strong> <strong>Schedule</strong> <strong>Final</strong> <strong>Rule</strong>
<strong>Impact</strong> on Nephrology Specialty
On November 1 CMS released the final rule for the <strong>2013</strong> <strong>Medicare</strong> Physician <strong>Fee</strong>
<strong>Schedule</strong>. While the news for nephrology is close to a break-even proposition for dialysis
services, CMS made deep cuts to the relative value units (RVUs) for angioplasty services
commonly provided by nephrologists. Overall, the specialty is slated to experience a 0%
impact (i.e., no change) as a result of the proposals in the <strong>2013</strong> fee schedule. The RVUs
for dialysis care actually tick up slightly from what was outlined in the proposed rule,
with the most substantial increase (1%) in the RVUs for CPT code 90966, the adult home
dialysis code.
Dialysis Services
The final rule tracked fairly closely with what CMS outlined for dialysis care in the
proposed rule; the impacts are noted below, with differences from what was in the
proposed rule noted in bold.
Inpatient Dialysis Services
• 90935 (hemodialysis, single evaluation) is reduced by 2.3%
• 90937 (hemodialysis, repeated evaluation) is reduced by 2.0% (1.9 in proposed
rule)
• 90945 (dialysis, one evaluation) is increased by less than 1%
• 90947 (dialysis, repeated evaluations) is reduced by less than 1%.
Outpatient Dialysis Services
Of the 18 applicable CPT codes (adult and pediatric, in-center and home, monthly and
daily), all but three have revisions up or down of less than 1%, or are unchanged. The
adult four visit MCP code (90960) is reduced 0.6%, while the adult 2-3 visit code
(90961) is increased 1.1%.
The exceptions are:
• 90951 (monthly ESRD services, 4 visits, less than two years old) is reduced by
1.8% (1.5% in proposed rule)
• 90962 (adult monthly ESRD services, single visit) is increased by 1.1% (2% in
proposed rule)
• 90967 (daily/home ESRD services, less than 2 years old) is reduced by 3.7%
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Angioplasty Code Reductions
With regard to the angioplasty codes (CPT codes 35475—arterial angioplasty, and
35476—venous angioplasty), the total RVUs for these services were unilaterally reduced
by CMS by approximately 28% and 15%, respectively, from the 2012 values for these
codes.
The reductions for these services came on the heels of review of the services by the
AMA’s Relative Value Update Committee (RUC) in April 2012. As part of the RUC
review process, RPA, the American Society of Diagnostic and Interventional Nephrology
(ASDIN), and allied groups surveyed these codes and presented a collaborative proposal
for valuing the services to the RUC. While the RUC review did result in a slight
reduction of the work values for the codes from previous levels, it was relatively minimal
and the practice expense values for these services (which represents the majority of the
overall value for the services) was preserved. Thus, while the RVUs for the services
were reduced, the vast majority of the total value of the services was preserved, and in
light of the fact that CMS has traditionally accepted 80-90% of RUC recommendations,
RPA and ASDIN believed that the review of the angioplasty codes had been a success
overall.
However, upon review of the final fee schedule rule released by CMS on November 1 it
is clear that CMS did not accept the RUC recommendations. CMS agreed with the
RUC’s approach of selecting a similar service as a starting point for RVU development,
removing overlapping work inputs, and arriving at a recommended RVU for the service.
Unfortunately, CMS selected for the starting points services with substantially lower
work RVUs. As a result, while the RUC recommended 6.60 work RVUs for 35475,
CMS assigned a work RVU of 5.75 to the service. Similarly, in contrast to the RUC
recommendation of 5.50 for 35476, CMS assigned a work RVU of 4.71 to the service.
CMS does note in the rule that these RVU levels are being assigned to the services on an
interim final basis, and RPA will submit comments to the Agency that will point out the
counterproductive impact these reductions may have on fistula creation for kidney
disease patients. However, the advocacy effort to convince CMS to reconsider and
upwardly revise the RVU levels for these services will be quite challenging.
E-Prescribing Changes/Meaningful Use (MU) Hardship Exemptions
The final rule outlined several changes to the e-prescribing program, as noted below:
• The definition of group practice for the eRx Incentive Program is now tied to the
definition of group practice under PQRS. Since CMS is changing the definition of
group practice in PQRS to allow groups of 2-24 eligible professionals (EPs) to
participate in PQRS as a group practice, accordingly, group practices of 2-24
eligible professionals will be able to participate in the eRx Incentive Program as a
group practice in <strong>2013</strong> (that is, for the <strong>2013</strong> incentive and 2014 payment
adjustment).
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• To be a successful electronic prescriber for the <strong>2013</strong> incentive, group practices
comprised of 2-24 EPs that are participating in the eRx GPRO must report the
electronic prescribing measure at least 75 times during the applicable 12-month
reporting period (January 1, <strong>2013</strong> – December 31, <strong>2013</strong>) for the <strong>2013</strong> incentives.
For 2014, group practices comprised of 2-24 EPs that are participating in the eRx
GPRO must report the electronic prescribing measure at least 75 times during the
applicable 2014 6-month payment adjustment reporting period.
With regard to new MU hardship exemptions:
• To qualify for a significant hardship exemption under this category for the <strong>2013</strong>
payment adjustment, an eligible professional (or every eligible professional in a
group practice participating in the eRx GPRO for the <strong>2013</strong> payment adjustment)
must have achieved meaningful use of Certified EHR Technology under the EHR
Incentive Program for a continuous 90-day EHR reporting period that fell within
the 12-month (January 1, 2011 – December 31, 2011) or 6-month (January 1,
2012 – June 30, 2012) payment adjustment reporting period or for an EHR
reporting period that is the full CY 2012.
• To qualify for a significant hardship exemption under this category for the 2014
payment adjustment, an eligible professional (or every eligible professional in a
group practice participating in the eRx GPRO) must achieve meaningful use of
Certified EHR Technology under the EHR Incentive Program for a continuous
90-day EHR reporting period that falls within the 12-month (January 1, 2012 –
December 31, 2012) or 6-month (January 1, <strong>2013</strong> – June 30, <strong>2013</strong>) payment
adjustment reporting period or for an EHR reporting period that is the full CY
2012.
Other Issues
• SGR Reduction—The final rule also includes a statutorily required 26.5% acrossthe-board
reduction to <strong>Medicare</strong> payment rates. The press release for the rule
states that “for more than 1 million physicians and non-physician practitioners
under the Balanced Budget Act of 1997’s Sustainable Growth Rate (SGR)
methodology. However, Congress has overridden the required reduction every
year since 2003. The Administration is committed to fixing the SGR update
methodology and ensuring these payment cuts do not take effect. Predictable,
fiscally-responsible physician payments are essential for <strong>Medicare</strong> to sustain
quality and lower health care costs over the long-term.”
• New Discharge Care Management Codes—CMS also finalized two new postdischarge
care management codes that pay providers for care coordination that
occurs outside of a face-to-face visit. These codes are:
o 99495, Transitional Care Management Services, moderate complexity,
requiring a face-to-face visit within 14 calendar days of discharge; and
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o 99496, Transitional Care Management Services, high complexity,
requiring a face-to-face visit within 7 calendar days of discharge
Note: The new discharge management codes are not applicable to MCP patients.
• Value-Based Modifier—In addition, the final rule continues the careful
implementation of the physician value-based payment modifier by phasing in
application of the modifier and enabling physicians in larger groups to choose
how to participate. The value-based modifier provides differential <strong>Medicare</strong>
payments to physicians based on comparison of the quality of care furnished to
beneficiaries and the cost of care. The statute allows CMS to phase in the value
modifier over three years from 2015 to 2017. For 2015, the final rule applies the
value modifier to groups of physicians with 100 or more eligible professionals, a
change from the proposed rule, which would have set the group size at 25 or
above. This change was adopted to gain experience with the methodology and
approach before expanding it to smaller groups.
Kidney-Related PQRS <strong>2013</strong> Measures
CMS included the following kidney-disease related measures in the final rule, which are
unchanged from those published in this summer’s proposed rule.
Measure # Measure Title Description Reporting Option
No NQF #/
Claims
No PQRS #
Registry
NQF 1667/
No PQRS #
NQF 0323/
PQRS 81
Pediatric End-
Stage Renal
Disease
Measure
(AMA/ASPN):
Pediatric
Kidney
Disease:
Adequacy of
Volume
Management
Pediatric
Kidney
Disease:
ESRD
Patients
Receiving
Dialysis:
Hemoglobin
Level

NQF 0321/
PQRS 82
AQA
adopted/
PQRS121
(This would
seem to be
NQF #1668)
AQA
adopted/
PQRS 122
AQA
adopted/
PQRS 123
Adequacy:
Solute
Adult Kidney
Disease:
Peritoneal
Dialysis
Adequacy:
Solute
Adult Kidney:
Disease
Laboratory
Testing
(Lipid Profile)
Adult Kidney
Disease:
Blood Pressure
Management
Adult Kidney
Disease:
Patients On
Erythropoiesis -
Stimulating
Agent (ESA)
- Hemoglobin
Level > 12.0
g/dL
ESRD receiving hemodialysis
three times a week who have a spKt/V ≥
1.2
Percentage of patients aged 18 years and
older with a diagnosis of ESRD receiving
peritoneal dialysis who have a total Kt/V ≥
1.7 per week
measured once every 4 months
Percentage of patients aged 18 years and
older with a diagnosis of CKD (stage 3, 4,
or 5, not receiving Renal
Replacement Therapy
[RRT]) who had a fasting
lipid profile performed at
least once within a 12-month period
Percentage of patient visits for those
patients aged 18 years and older with a
diagnosis of CKD (stage 3, 4, or 5, not
receiving Renal Replacement Therapy
[RRT]) and documented
proteinuria with a blood
pressure < 130/80 mmHg
OR ≥ 130/80 mmHg with
a documented plan of care
Percentage of calendar months within a 12-
month period during which a Hemoglobin
level is measured for patients aged 18 years
and older with a diagnosis of advanced
Chronic Kidney Disease (CKD) (stage 4 or
5, not receiving Renal Replacement
Therapy [RRT]) or End Stage Renal
Disease (ESRD)
(who are on hemodialysis
or peritoneal dialysis) who
are also receiving ESA
therapy AND have a
Hemoglobin level > 12.0 g/dL
Registry
Claims
Registry
Measure Groups
Claims
Registry
Measure Groups
Claims
Registry
Measure Groups
The final rule will be officially published in the Federal Register on November 16, and
comments will be due on or around December 31. Check the RPA website at
www.renalmd.org after that date to review RPA’s comments.
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