CKD is a silent, growing problem in the United States. Although fewer than 1% of the population has Stage 4 CKD (glomerular filtration rate of 15 to 30 mL/min/1.73m2), the incidence has increased 67% over the last 20 years.1 Among people over age 65 years, the rate of growth in the incidence of Stage 4 CKD has been 4.6 times greater than in the general population.2 As kidney function decreases, a patient's risk of death from myocardial infarction or stroke doubles because of the higher cardiovascular burden (Figures 1 and 2). Because effective treatments for CKD can slow or stop progression to end-stage renal disease (ESRD), patient education is vital.3–7
To decrease the incidence of ESRD and provide better care for patients with CKD, Congress authorized Medicare to reimburse providers for up to 6 kidney disease education classes for eligible Medicare beneficiaries with Stage 4 CKD.8,9 These classes would be taught by a qualified practitioner, defined as a physician, PA, NP, or clinical nurse specialist (CNS).8,9 Classes can be taught in an individual or group setting, and on the same day as an office visit. The sessions (31 minutes is considered an hour-long class) can be in individual classes or a block of up to 6 hours. Classes must include management of comorbid conditions such as cardiovascular disease, diabetes, hypertension, anemia, metabolic bone disease, neuropathy, and uremic complications; a review of available renal replacement therapies; strategies to slow progression of kidney loss; and patient engagement in treatment decisions.8,9 The classes also must address the needs of patients with disabilities, limited English proficiency, or low health literacy.10,11
The nephrology community initially believed that PAs and NPs would be the primary instructors for these classes. To determine if this was the case, descriptive statistics were applied to the Center for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary Master Public Use File for 2010 and 2011.
Kidney disease education classes are billed under two G codes: G0420-individual and G0421-group, and cannot be billed “incident-to,” so instructors, sites, and reimbursement denials can be identified in the main CMS database billing records. An institutional review board waiver was granted by Chesapeake Research Review under the Department of Health and Human Services regulation 45CFR46. Analysis of the CMS Public Use File required consultant help to convert compressed files into a spreadsheet for data analysis. The Public Use File lists all billed kidney disease education classes (G0420, G0421), instructor codes, class site codes, and all reimbursement denials. Classes that have similar demographics are grouped by CMS into one data point. By subtracting the denied classes from the billed classes, the actual number of reimbursed classes can be obtained. A reimbursement denial for kidney disease education classes may be due to the wrong provider identifier, an incorrect diagnosis code, a non-authorized provider or site, or a problem with the CMS Medicare administrative contractor.
Tabular calculations of the reimbursed classes were done by using the practitioner and site codes available on the CMS.gov Web site. For purposes of calculations, classes taught by clinical nurse specialists were combined into the NP database.
Individual classes (G0420) 4,580 individual classes were taught in 2010, and 6,714 in 2011, a 47% increase (Figure 3). Table 1 shows the breakdown of instructors and sites for individual classes. In 2010, all home classes were taught by either a PA or an internal medicine physician (Table 2); in 2011, home classes were taught by PAs, internists, and in two cases by hospital-based practitioners. Nephrologists and NPs taught no home classes in either 2010 or 2011. Ten times more home classes were taught in 2011 than 2010 (483 vs. 48). Kidney disease education classes were taught in skilled nursing homes and dialysis units by nephrologists; general practitioners taught all the nursing home classes.
In 2010, all reimbursement denials (<1%) for classes occurred in office billing, compared with 2011, when the dialysis unit was the most denied site (accounting for 77% of denials) for reimbursement by Medicare.
Group classes (G0421) The number of group classes increased 48% from 2010 (1,612 classes) to 2011 (2,390 classes (Figure 4). Table 3 shows the breakdown of instructors and sites for group classes. In 2010, there were 14 denied claims: 9 by nephrologists and 5 by PAs and NPs. In 2011, there were 482 denied claims, including 308 for PAs and NPs, 153 for nephrologists, and 14 for internists. All 7 claims by neurologists, clinical labs, group practices, and “unknown” were denied in 2011, as were all dialysis unit sites billed by nephrologists.
Kidney disease education classes are mandated by Congress for Medicare beneficiaries with Stage 4 CKD and follow strict guidelines regarding instructor, topics, and sites of classes.9 A “one-hour” class must be 31 minutes long, taught by a physician, PA, NP, or CNS, and cannot be billed as “incident-to.”10 However, the class can be taught on the same day as an office or hospital visit, and up to six classes can be taught on the same day.
The 2011 reimbursement for classes was $110.42 ($93.86 at 85%) for an individual class and $26.16 ($22.24 at 85%) for a group class.12 To be financially feasible, a group class must have six or more Medicare beneficiaries; because of HIPAA guidelines against sharing patient-specific information, individual classes predominate.13 PAs and NPs are the preferred choice for teaching the group classes but we argue that they are underused as instructors in the individual classes. This may be related to failure to capture the charges for both the class and an office visit.
A review of the kidney disease education billing for 2010 and 2011 identified trends in educational classes. Few billings for classes were denied in 2010, but 2011 showed a more refined approach by the Medicare administrative contractors. Statistically, offices accounted for the largest share of claim denials in 2011 (14%); however, dialysis unit billings were the most likely to be denied. This is due to the Medicare regulation that providers may not teach kidney disease education classes in a dialysis facility. Unlike 2010, no payments were made in 2011 to dietitians or laboratories, neither of which are authorized practitioners under the kidney disease education regulations.8
Home classes increased 100-fold between 2010 and 2011, with all classes taught by PAs, family practitioners, or internists. With the increase in time needed for a home class, the use of PAs or NPs would make financial sense. CMS has stated that a kidney disease education class also can be billed on the same day as an evaluation/management visit, leading us to believe that the incidence of kidney disease education home classes is actually ridiculously low. The extension of kidney disease education classes into the skilled nursing facility marks a welcome increase in reaching the more fragile patients and the chance to discuss medical management of CKD. Interestingly, all classes at skilled nursing facilities were taught by nephrologists, and all classes at nursing homes were taught by general practitioners. With the significant use of PAs and NPs in the nursing home, this seems to be a lost chance for PAs and NPs to teach these classes.
Classes taught while patients are in the hospital continue at a very low rate and may be amenable to adjustment. Again, a combination of a kidney disease education class and an evaluation/management visit can be billed on the same day and the inpatient hospital would be an excellent place for this to occur.
Outpatient hospital classes are more likely to be group classes and taught by a nephrologist; PAs and NPs taught the majority of group office classes. A small but stable number (2%) of classes were taught by neurologists in 2010 and 2011. These may either be practitioners who are mislabeled by CMS as neurology rather than nephrology or patients referred for neuropathy who are first given a diagnosis of CKD in the neurology office.
The nephrology community, providers, patients, and dialysis organizations banded together to push for Medicare reimbursement for education for patients with CKD. Evidence-based research presented to Congress and CMS convinced them of the financial usefulness of kidney disease education classes.3 Most of the increase in total classes taught from 2010 to 2011 came from the increase in individual classes (6,714 in 2011 vs. 4,580 in 2010). With 110,000 patients starting renal replacement therapy each year, less than 7% of eligible Medicare patients are receiving kidney disease education.14 Practices have stated that limited time, space, and personnel are the reason for the lack of kidney disease education class offerings.15 An increase in the use of PAs and NPs may help mitigate that problem.
Although using the CMS Public Use File allows access to every kidney disease education class billed, it does not identify the specialty of the PA or NP. Within the physician designations, one can tease out the type of physician specialty teaching the classes. This is not possible for PAs and NPs. Previous work by the authors has shown that most nephrology practices offer kidney disease education classes to all their patients with Stage 4 CKD, rather than only patients on Medicare, billing the commercial patients under an evaluation/management code and writing off the uninsured patients.15 This type of billing for commercial and uninsured patients will undercount the total number of kidney disease education classes offered nationwide.
The nephrology community believed that a standardized program, taught by practitioners knowledgeable in CKD, would decrease the number of patients progressing to ESRD and allow research possibilities into patient behavioral change, transplant referral, and an increase in home modalities.16–18 With less than 7% of eligible patients receiving kidney disease education, this promise is unrealized.15 PAs and NPs are underused for kidney disease education but are a linchpin in the propagation of these classes. Although PAs and NPs teach the bulk of group and home classes, they are less used in the office and nursing homes. Harnessing the PA and NP communities to increase the number of kidney disease education classes means that fewer patients will progress to ESRD, saving patients and communities the personal and financial costs that accompany dialysis and transplant.
Outreach attempts from PAs and NPs in nephrology to their colleagues to increase kidney disease education classes should help to mitigate the problem.19
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2. US Renal Data System. 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States
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8. CMS Manual Systems. Coverage of Kidney Disease Education Patient Services, Section 152 (b): Coverage of Kidney Disease Patient Education Services
. Baltimore, MD: Department of Health and Human Services, Center for Medicare and Medicaid Services; July 7, 2009.
9. Federal Register
10. CMS Manual Systems. Coverage of Kidney Disease Education Patient Services, Pub100–02, Medicare Benefit Policy
. Baltimore, MD: Department of Health and Human Services, Center for Medicare and Medicaid Services; December 18, 2009.
11. Department of Health and Human Services. Quick Guide to Health Literacy
. Accessed July 6, 2011.
13. Department of Health and Human Services. Health Information Privacy: 45 CFR 164.502(g)
. Washington, DC; December 3, 2002. Revised April 3, 2003.
14. Saggi SJ. Dialysis Advisory Group of American Society of Nephrology. Considerations in the optimal preparation of patients for dialysis. Nat Rev Nephrol
15. Zuber K, Davis J, Rizk DV. Kidney disease education one year after the Medicare Improvement of Patients and Providers Act: a survey of US nephrology practices. Am J Kidney Dis
16. Tuot DS, Plantinga LC. What patients don't know may hurt them: knowledge and the perception of knowledge among patients with CKD. Kidney Int
17. Goovaerts T, Jadoul M, Goffin E. Influence of a predialysis education program on the choice of renal replacement therapy. Am J Kidney Dis
18. Kutner NG, Johansen KL, Zhang R, et al. Perspectives on the new kidney disease education benefit: early awareness, race and kidney transplant access in a USRDS study. Am J Transplant
19. Mondry A, Zhu AL, Loh M. Active collaboration with primary care providers increases specialist referral in chronic renal disease. BMC Nephrol
© 2013 American Academy of Physician Assistants.