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Submit Under Private Insurance Coverage: Cpt Code #90940
- Letter to the Insurance provider (MS Word Document)- A sample predetermination letter to a private insurance carrier, explaining the proposed patient charges. It should be personalized to the costs incurred at your clinic for access flow measurements.
- Vascular Access Cost Worksheet (Excel Spreedsheet)- This is a set of insurance cost recovery worksheets to assist the insurance company in determining their cost savings in reimbursing indicator dilution access flow studies.
The case for Medical Reimbursement for Monthly Hemodialysis Access Flow Tests: Transonic Opinion
USA hemodialysis patients experience higher morbidity and mortality rates than patients in Western Europe and Japan1 . In order to improve quality of care, the National Kidney Foundation (NKF) initiated the "Dialysis Outcomes Quality Initiative" ("DOQI")2.
A major finding was that "...an aggressive policy for monitoring AV graft patency extends graft life and minimizes graft thrombosis (Guideline 10: Monitoring Dialysis
AV Grafts for Stenosis3). Thus, much access-related morbidity and associated costs are avoidable."...[Q]uality of life and overall outcomes for
hemodialysis patients could be improved significantly by... Detecting access dysfunction prior to access thrombosis."2
"Early detection and treatment of stenosis reduces the frequency of thrombosis and reduces access
replacement rates by up to 70%" according to the Vascular Access K/DOQI Guidelines, published by the NKF.4 The guidelines also state that "dialysis AV grafts should be monitored to permit early detection of hemodynamically significant stenosis with the goal of reducing the thrombosis rate".4 Furthermore, intra-access flow measurements are the preferred method for surveillance of AV grafts and fistulas, and cite “to date, ultrasound dilution …..[has] been most extensively evaluated.....[F]low measurements by ultrasound dilution are reliable and valid…..and can be done on-line during dialysis thereby providing rapid feedback”.4
A study by Vanderbilt University and Renal Care Group in Nashville reports "total vascular access related
costs were reduced by 48.5% for Vascular Access Blood Flow Monitoring (VABFM) vs. non-monitoring".5 These costs include a reduction in related costs of 78% for hospitalizations, 82% for catheter placements and 90% for thrombectomies. Gambro Healthcare found "a dedicated multidisciplinary team approach to vascular access care resulted in a 44% reduced incidence of thrombosis and significantly improved clinical outcomes compared to standard care."6 Both these studies were conducted with the Transonic ultrasound indicator dilution access flow monitor, the same device as used in the studies leading to the K/DOQI guideline recommendations.
The American Medical Association has responded to the 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. The Centers for Medicare and Medicaid Services (CMS) has not yet assigned this CPT code a monetary value, however, there is now strong evidence that the application of the K/DOQI guideline will save substantial amounts of money in vascular access related costs to the insurance providers.
The national average for total vascular access related treatment costs is $8,000 per patient per year.7 Even at a conservative 30% savings in total vascular access related treatment costs, the insurer stands to gain $2,400 per patient per year from a clinic’s implementation of flow-based screening for access stenosis.
However, the existence of a code does not automatically imply that insurers will pay under the code – they need
to be convinced, one by one, that payment is cost-effective and improves quality of life. It is our expectation that:
CMS will want to hear from the hemodialysis providers and medical experts before
deciding to honor the code. Given the strength of arguments and broad support for this medical test, it is our expectation that Medicare reimbursement will also fall
in place.
Indeed 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 now open to hear arguments why it should
reverse this ruling.
Please contact the regional and national administrators you know at CMS and Medicare and
educate them on the benefits of access flow measurements.
Some Arguments for supporting Medicare Reimbursement:
- Administering the DOQI-recommended monthly diagnosis of the progression of access disease requires an
investment in hardware and labor. Providers cannot be expected to foot the bill for this without reimbursement assistance.
- Reimbursement will reduce cost to the taxpayers by reducing procedural expense, morbidity and mortality
related to access failure and hospitalization6.
- Without reimbursement, the quality of care for USA ESRD patient will fall further behind W-Europe and Canada7.
- The current CMS ruling is based on incomplete information8,9.
References:
- "NKF Dialysis Outcomes Quality Initiative, Hemodialysis Adequacy Clinical Practice Guidelines", Am J
Kidney Disease Vol.30 No.3, Suppl.2, Sept.1997, Introduction pp.S17: "Despite a longer life expectancy for the general population of the United States in
comparison to that of most other industrialized nations, several analyses have reported that gross and adjusted annual mortality of Americans with end-stage renal
disease greatly exceeds the analogous rates observed in other countries."
- "NKF Dialysis Outcomes Quality Initiative, Vascular Access Clinical Practice Guidelines", Am J
Kidney Disease Vol.30 No.4 Oct.1997, Introduction pp.S152-153
- Ibid, Guideline 10, "Monitoring Dialysis AV Grafts for Stenosis, pp.S162-164.
- Vascular Access K/DOQI Guidelines, National Kidney Foundation, 2000.
- McCarley, P. WIngard, R.L., Shur, Y., Pettus, W., Hakim, R.M., Ikizler, T.A., "Vascular access blood flow monitoring reduces access
morbidity and costs," Kidney International, Vol. 60, p. 1164-1172, 2001.
- Duda, C.R., Spergel, L.M., Holland, J., Tucker, C.T., Bosch, J.P., Bander, S.J., "A Multidisciplinary
Vascular Access Care Program (VACP) Enables Implementation of Dialysis Outcomes Quality Initiative (DOQI)," JASN Abstracts, Vol. 10, p. 206A, 1999.
- 2000 Annual Data Report, United States Renal Data System.
- The CMS ruling cites that "Doppler flow studies... may be used for diagnostic purposes..., these
indicator dilution studies are used for monitoring purposes only" and that the indicator dilution study requires a follow-up imaging study while a Doppler flow
study would not.
- The NKF DOQI Guideline 10 recognizes indicator dilution studies as tests that will diagnose stenosis disease
just as Doppler studies (and with better accuracy!). The practice of doing a Doppler study to confirm stenosis diagnosed with dilution technology flow studies dates
back to the 1995-1997 development phase of this novel measurement technique. The dilution technology flow studies have now demonstrated higher accuracy than Doppler
studies; once reimbursement is in place there seems no need to confirm its diagnosis with a lesser-accuracy test such as Doppler.
- The cost of creating and maintaining the hemodialysis access has been estimated at 15% ($2.4 billion/yr), of
the overall cost of hemodialysis care ($16 billion/yr for year 2000). [Data extrapolated from US Renal Data System: 1999 Annual Data Report.] Approximately 90% of
these hemodialysis access costs are borne by the USA taxpayer via Medicare disbursements ($2.2 billion/yr). Cost savings possible under an aggressive access management
program have been estimated at 50% of this ($1.1 billion/yr).
- Transonic data reveals that countries with socialized medicine have been quick to implement the DOQI access
flow test guideline (Canada: 75%, France: 40%, Holland: 90% of clinics), but is hindered in the USA (15% of clinics) because of financial constraints. Conceived,
developed and promoted in the USA, this technology now widens the gap in quality of care between the USA and other developed countries!
- Both Doppler and indicator dilution studies are routinely followed by an angiogram imaging study. A Doppler
study does not offer cost savings in the follow-up procedures.
- Integral to the DOQI-recommended diagnosis of the progression of stenosis is monthly testing. While Doppler
access studies certainly have their place in certain diagnostic settings, their cost and complexity prohibits their use for monthly screening of the access to diagnose
critical stages of stenosis.
Copyright 01/05, Transonic Systems Inc
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