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)
Let's review some of the benefits enhancements offered by the KCC models.
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:
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:
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:
ESRD Physician services:
Medical nutrition therapy codes:
Transitional Care Management:
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:
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.
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.
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.
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.
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