Physician Fee Schedule Changes a Win for Nephrologists, Home Dialysis

David White
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Nephrologists will see payment increases in some services starting January 1, 2021, according to the proposed rule on the annual physician fee schedule released last month by the Centers for Medicare & Medicaid Services (CMS). In general, nephrology will see an overall 6% increase with an approximately 30% increase for home dialysis services.

Anupam Agarwal, MD, FASN, ASN President, praised the move by CMS: “Finally, after years of advocacy by ASN, Medicare is supporting nephrologists with rates that better reflect our work. Most importantly, this is a big win for home dialysis, a top priority for ASN.”

Payment and codes

CMS also proposed changes to the payment of transitional care management (TCM) and what codes can be billed with TCM services (Table 1). CMS added 14 End Stage Renal Disease (ESRD) codes to the list that may be billed with the TCM. TCM accounts for all the services by clinicians during the 30-day post-discharge period for patients discharged from hospitals. This includes the 7- or 14-day face-to-face visit. This visit does not have to meet a documentation level of service such as a 99214 or 99215 other than the medical decision-making component.


The increase in nephrology payments was due to the upward adjustment of relative value units (RVUs) being updated and applied to nephrology billing codes. However, the calculation of RVUs to adjust home dialysis rates became a source of great confusion at the time of the release of the proposed rule. The text of the proposed rule stated the RVU adjustment for CPT 90966 showed an increase from 4.26 to 8.04 RVUs—signaling an 89% increase for home dialysis rates. However, attached to the proposed rule was an Excel spreadsheet showing an increase to 5.52 RVUs for home dialysis establishing parity with two to three in-center MCP visits or a 31% reimbursement increase. This confusion led some in the kidney community to speculate that there had been a behind-the-scenes battle over “how much” to raise home dialysis reimbursement.


The kidney community had expected a set of recommendations regarding which telehealth waivers or expansions made under the public health emergency (PHE) owing to COVID-19 might be made permanent for those CMS has the authority to extend and and an indication of those the agency believes Congress will need to take action to extend. For the most part, this did not happen. Instead, CMS placed most ESRD-related service expansions in a newly created Category 3—the future of which is far from clear in the proposed rule. CMS invited comment on the fate of items in Category 3 as to whether commenters want the waivers/expansions to be made permanent. The American Society of Nephrology (ASN) is preparing comments on telehealth expansions and other nephrology-related changes under the PHE. Those comments are due to Medicare by October 5, 2020.

For the most part, the following are the telehealth changes to Medicare in the PHE:

  • Geographic and site restrictions were waived. Telehealth services were available across the country, allowing originating sites to be everywhere including the home and dialysis facilities.

  • Provider lists were expanded, adding care team members to those originally approved to conduct and bill for telehealth services.

  • Services were expanded, adding over 80 additional codes, including those for home and in-center dialysis.

  • Modalities including video were expanded to include audio only in some cases.

  • Supervision and licensing requirements were relaxed.

  • Payment parity was established for audio only when asynchronous video/audio is not possible.

  • Telehealth was opened to new patients in addition to existing patients.

Making these changes permanent requires action by either CMS or Congress depending on the change.

  • Geographic and site restrictions would need congressional action to become permanent.

  • Changes to the modality (audio/video) requirements do not require congressional action; however, CMS is unlikely to take action without congressional approval. Federal law only requires it to be a telecommunications system, but in regulations CMS has required it to be an “interactive” telecommunications system—not audio only—while also using language prohibiting phones from meeting that definition. The phone language, however, was amended and is likely to remain permanently.

  • Permanent expansion of providers able to provide telehealth and bill for it would also require congressional action.

  • Permanent expansion of services (expanding CPT codes approved for telehealth), for the most part, can be done by CMS.

Medicare appears to be cautiously awaiting both congressional approval and healthcare stakeholder support.

Quality Payment Program

As of 2019, and the release of the proposed physician fee schedule for calendar year 2020, CMS has included the Quality Payment Program (QPP) within the fee schedule rule. Previously, it had its own separate set of rule-making. The QPP, the value-based payment system that went into effect on January 1, 2017, has two payment pathways: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPM). Not many major changes were proposed for calendar year 2021, and most of those included were prescribed by statute when Congress created the program in 2015. Here are a few proposed changes:

  • Beginning Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) implementation was delayed until 2022 instead of 2021.

  • Increasing the performance threshold from 45 points for the 2020 performance year to 50 points for 2021 (10 points less than the 60-point threshold finalized for 2021 in the CY 2020 PFS Rule due to the PHE).

  • Revising performance category weights for Quality (decreases from 45% to 40%) and Cost (increases from 15% to 20%).

  • Removing the CMS Web Interface as a collection type and submission type for reporting MIPS quality measures beginning with the 2021 performance period.

  • Sunsetting the Alternative Payment Model (APM) Scoring Standard and allowing MIPS-eligible clinicians in APMs the option to participate in MIPS and submit data at the individual, group, or APM Entity level.

  • Updating third party intermediary approval criteria as well as remedial action and termination criteria.

New APM Performance Pathway (APP) in 2021; Complex Patient Bonus COVID-19 Update

CMS also proposes implementing an APP ahead of schedule in 2021. Performance category weights under the APP would be: 50% for Quality, 30% for Promoting Interoperability, and 20% for Improvement Activities.

The APP would be:

  • complementary to MVPs, composed of a fixed set of measures for each performance category.

  • available only for MIPS-eligible clinicians in MIPS, APMs, and

  • reported by individual eligible clinicians, groups, or APM Entities.

Medicare is also proposing to make a one-year only adjustment for 2021 to increase the complex patient bonus from a 5- to 10-point maximum for clinicians, groups, virtual groups, and APM Entities for 2020 performance only to offset the additional complexity of the patient population due to COVID-19.