Submit Under Private Insurance Coverage: CPT Code #90940
Transonic Opinion: Medical Reimbursement for Monthly Hemodialysis Access Flow Tests

The National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (K/DOQI) Guidelines have improved the clinical care of dialysis patients and standardized a comprehensive approach to vascular access management¹. The updated 2006 KDOQI Clinical Practice Guidelines for Vascular Access recommend that each dialysis facility have in place an organized program for the prospective diagnosis of venous stenosis by means of monitoring and surveillance². The KDOQI guidelines are reinforced through the Fistula First Initiative which recommends vascular access surveillance as well as standard procures to ensure vascular access function³.

The 2006 KDOQI guidelines recommended that patients should be referred for fistulogram if access flow is less than 600ml/min in graft or access flow 1,000ml that has decreased by more than 25% over 4 months².  Access Flow Measurement is known as the best validated and mostly widely recommended technique for detecting hemodynamically significant stenosis ^{4 5}. In fact, numerous publications have supported that regular vascular access surveillance will reduce thrombosis rates, improve quality of patients’ lives, and save considerable amounts of money in vascular access related costs to the insurance providers⁵

The American Medical Association (AMA) has responded to the National Kidney Foundation (NKF)’s call to improve access patency management through intra-access flow measurement. The AMA issued CPT Code #90940 effective January 2001 (“Hemodialysis access flow study to determine blood flow in grafts and arteriovenous fistulae by indicator dilution method, hook-up, measurement, and disconnection) for the NKF-recommended measurement approach.

However, the existence of a code does not automatically imply that insurers will pay under the code. The Centers for Medicare and Medicaid Services (CMS) has not yet assigned this CPT code a monetary value, CMS wants to hear from the hemodialysis providers and medical experts before deciding to honor the code and insurers need to be convinced that payment is cost-effective and improves quality of patients’ life. Given the strength of arguments and broad support for this medical test, it is our expectation that Medicare reimbursement will also fall in place.

CMS issued the initial ruling that “separate payment should not be made for these hemodialysis flow studies for ESRD patients once the new CPT codes have been established.” (Change Request 1117, Transmittal AB-00-55) CMS is always open to hear arguments why it should reverse this ruling and support access flow measurements.

Please contact the regional and national administrators you know at CMS and Medicare and educate them on the benefits of access flow measurements.

References:

1. NKF-KDOQI Clinical Practice Guidelines
2. KDOQI Clinical Practice Guidelines 2006
   
3. Fistula First Change Concepts
   
4. Sands JJ. Vascular access monitoring improves outcomes. Blood Purif 23:45-49, 2005  
5. Tessitore N et al, Adding access blood flow surveillance to clinical monitoring reduces thrombosis rates and costs, and improves fistula patency in the short term: A controlled cohort study. Nephrology Dialysis Transplantation 23:3578–3584, 2008
6. Maoz D et al, Hemodialysis graft flow surveillance with prompt corrective interventions improves access long-term patency. Clinical Nephrology 71(1):43-9, 2009
7. Kiaii M et al, A dedicated vascular access program can improve arteriovenous fistula rates without increasing catheters. Journal of Vascular Access Oct-Dec;9(4):254-9, 2008
8. Wijnen E et al, Impact of a quality improvement programme based on vascular access flow monitoring on costs, access occlusion and access failure. Nephrology Dialysis Transplantation 21(12):3514-9, 2006
9. Plantinga LC et al, Association of clinic vascular access monitoring practices with clinical outcomes in hemodialysis patients. Nephron Clinical Practice 104(4):c151-9, 2006
10. McCarley, P et al, Vascular access blood flow monitoring reduces access morbidity and costs. Kidney International Vol. 60, p. 1164-1172, 2001