The new kidney disease payment models, Kidney Care Choices, offer several intriguing incentives for aligned beneficiaries. In particular, the Benefit Enhancements offer reimbursement coverage for services that nephrology practices and care management teams are already rendering, that are in addition to the standard payments (Adjusted MCP, CKD QCP, and KTB, and the performance bonuses). For practices who are looking for incentive alignment to build these programs, KCC benefits enhancements will help provide the financial resources to do so. 

There are three planned benefits enhancements in the KCC Model that are mentioned in the Request for Applications (RFA)

1. Kidney Disease Education (KDE) Benefits
2. Telehealth Benefits
3. Post-Discharge Home Visits Benefit

Let's review some of the benefits enhancements offered by the KCC models.

1) Kidney Disease Education (KDE)

The goals of KDE benefit, as per the RFA:

"To ensure beneficiaries are informed about the effects and treatment of kidney disease, diet and nutrition, transplantation, dialysis modalities, and vascular access"

One clear lapse in the current Medicare KDE benefit is that it's exclusively limited to CKD stage 4 patients. Aligned beneficiaries in KCC are able to use this benefit waiver.

Scouring fee-for-service Medicare benefits guidelines, the relevant HCPCS codes for KDE are:

• G0420 Face-to-face educational services related to the care of chronic kidney disease; individual, per session, per one hour
• G0421 Face-to-face educational services related to the care of chronic kidney disease; group, per session, per one hour

Extension of the KDE service to CKD 4, 5, and new ESRD patients is just common sense. Educational sessions for planning their impending renal replacement therapy should be provided to most CKD 4/5/ESRD patients to cope with the tough transition to renal replacement therapy process.

What KCC Benefits Enhancement brings for KDE:

• CKD Stage 4, Stage 5, and patients within the first 6 months of ESRD qualify
• The original Medicare KDE must be rendered by a physician, physician assistant, NP, or a clinical nurse. This requirement will now be waived. Because topics can cover SDOH, nutrition, logistics and education, this will help share much of the physician workload with other clinicians or care providers working alongside you in your practice
• The topic of delaying dialysis initiation will now not need to be part of the KDE session.

2) Telehealth

For CY 2020, CMS is recognizing some kidney-disease relevant codes as eligible for telehealth (you can review the full telehealth code list from CMS here). Telehealth is all the rage, but it's also been difficult to get proper approval for reimbursement from Medicare given the finicky requirements (such as Health Professional Shortage Area requirement). Nevertheless, these telehealth CPT/HCPCS codes will be eligible according to current CMS guidelines.

Evaluation and Management (E&M) codes:

• 99201-99205: Office visit for new patient
• 99211-99215: Office visits for established patients
• 99307-99310: Subsequent Nursing Facility Care

ESRD Physician services:

• 90960-90962: MCP codes for ESRD
• 90963-90970: Other dialysis codes

Medical nutrition therapy codes:

• ‍97802-97804, G0270, G0271

Transitional Care Management:

• ‍‍99495-99496

What KCC Benefits Enhancement brings to Telehealth:

There is some language in the KCC RFA regarding telehealth:

...a conditional waiver of the interactive telecommunications system requirement under section 1834(m)(1) of the Act and 42 CFR 410.78(b) for services including otherwise covered dermatology and ophthalmology services furnished using asynchronous store and forward technologies.

Upon doing some research, it appears that the KCC benefit enhancements effectively extends the coverage to some of the newer telehealth codes in the CMS pipeline.

There is a new HCPCS code:

• ‍G2010: Remote evaluation of recorded video and/or images submitted by the patient (e.g., store and forward) which is in the process for making it into the Medicare Fee Schedule.

The CMS RFA specifically mentions that retinal scan or digital image (e.g. chest X-ray) can be reviewed remotely. How far this extends is upto debate and the RFA leaves it open to interpretation and potential waiver. Creativity may be rewarded.

Asynchronous methods do not include telephone calls, images via fax machine, or text messages without visualization of the patient

Additionally, subject to approval, CMS will conditionally waive certain Medicare telehealth requirements for qualified entities to allow them to furnish telehealth services using asynchronous telecommunications systems

Translated: CMS will likely review what gets submitted during implementation year to evaluate what's covered and what's not.

‍

An additional tidbit on home dialysis with telehealth and remote patient monitoring:

Given the incentivization for home dialysis, there are some questions about whether remote patient monitoring applies as telehealth benefits enhancements - for example when a home dialysis patient needs remote machine data analysis. The short answer is no. However, the long answer is that there are newly approved codes (as of January 2020) for remote patient monitoring, 99453, 99453, 99457, which serve to replace an ancient, hard-to-utilize HCPCS code 99091.

One of the other benefits - the service can be rendered by the clinical staff (RN and medical assistants) which eliminates the need for any benefits waivers. If this applies to some home dialysis device monitoring evaluation, the proposed Medicare payment for these codes are $21, $69, $54, respectively.

A simple table borrowed from the Nixon Law Group to compare the new codes:

In short - the new remote patient monitoring code is much easier to use, with more sensible reimbursement requirements.

3) Post-Discharge Home Visits

Qualified beneficiaries are eligible for up to nine (9) post-discharge home visits within a 90 day period. Most post-discharge patients that nephrologists take care of are likely to necessitate some sort of high-frequency follow up that is more convenient for the patient than an office visit.

‍What KCC Benefits Enhancement brings:

• The prior Medicare requirement was that the home visit needs to be performed by a physician, or by another clinician under direct supervision of a physician. Under KCC Benefits, aligned beneficiaries can receive home visits performed by an "auxiliary personnel" with general supervision of a physician.

Just like the telehealth issue, the personnel requirement - needing to have physician directly supervising or attending the home visits - was the major deterrent to claiming this benefit. Under KCC, this requirement is waived, meaning nurses, medical assistants, and perhaps contract care providers, do not need to be physician supervised to provide these visits.

Commentary

There is a general pattern to these benefits enhancements - the current benefits were too restrictive, hindering practical adoption. Having physicians directly supervising KDE, Telehealth, or Post-Discharge Home Visits doesn't do much to preserve valuable physician resources.

It's clear that KCC Benefit Enhancements is trying to equip nephrology practices with extra hands and feet to outreach and engage more patients, aligning incentives to improve CKD and ESRD disease outcomes.

Being able to deploy dedicated auxiliary staff that focus on kidney disease education, telehealth consults, and post-discharge home visits will make it easier to do a much better job, clinically and operationally, than having busy clinicians splitting their time between clinic, hospital, and the home. 

pulseData partners with nephrology groups and care organizations to accelerate adoption of value-based payment models to bring data-driven optimal care delivery using our AI-powered care coordination platform. Contact us for more information! info@pulsedata.io

‍