CMS Kidney Disease CMS Kidney Disease Patient Education Patient Education

Benefit: Benefit: Hit or Miss?Hit or Miss?

Linda Shenton RN, MN, ACNP-BC, Linda Shenton RN, MN, ACNP-BC, CNN-NPCNN-NP

Nephrology Associates, P.A.Nephrology Associates, P.A.

ObjectivesObjectives

1. Identify the basic structure of the CMS 1. Identify the basic structure of the CMS Kidney Disease Patient Education (KDPE) Kidney Disease Patient Education (KDPE) benefit.benefit.

2. Discuss key components of the CMS KDPE 2. Discuss key components of the CMS KDPE of particular interest to nephrology nurses.of particular interest to nephrology nurses.

3. Critique of the CMS KDPE benefit.3. Critique of the CMS KDPE benefit.

To provide KDE services “…tailored to meet the needs To provide KDE services “…tailored to meet the needs of the individual beneficiary involved, to provide of the individual beneficiary involved, to provide opportunities to actively participate in the choice of opportunities to actively participate in the choice of therapy, and provide information regarding…”therapy, and provide information regarding…”

-Management of comorbidities (for the purpose -Management of comorbidities (for the purpose of delaying dialysis)of delaying dialysis)

-Prevention of uremic complications -Prevention of uremic complications

-Renal replacement options-Renal replacement options

Objective OneObjective One

Identify the basic structure of Identify the basic structure of the CMS KDPE benefit.the CMS KDPE benefit.

StructureStructure

Beneficiaries eligible for coverageBeneficiaries eligible for coverage

Qualified personQualified person

Limitations for coverageLimitations for coverage

Standards for contentStandards for content

Outcomes assessmentOutcomes assessment

Beneficiaries Eligible for Beneficiaries Eligible for CoverageCoverage

Medicare part B covered beneficiariesMedicare part B covered beneficiaries

Diagnosed with Stage IV CKD (severe Diagnosed with Stage IV CKD (severe decrease in decrease in

GFR; GFR value of 15-29ml/min/1.73mGFR; GFR value of 15-29ml/min/1.73m²²))

Referral from the physician managing the CKD Referral from the physician managing the CKD

Qualified PersonsQualified Persons

Medicare Part B covers KDPE services by a Medicare Part B covers KDPE services by a ‘qualified person’ meaning a:‘qualified person’ meaning a:

-Physician-Physician

-Physician assistant -Physician assistant

-Nurse practitioner-Nurse practitioner

-Clinical nurse specialist-Clinical nurse specialist

Non-qualified Persons?Non-qualified Persons?

Quoting directly from the Medicare Quoting directly from the Medicare document:document:

“ “ The following providers are not The following providers are not ‘qualified persons’ and are excluded ‘qualified persons’ and are excluded from furnishing KDPE services: a from furnishing KDPE services: a hospital, CAH, SNF, HHA, or hospice hospital, CAH, SNF, HHA, or hospice located outside of a rural area or a located outside of a rural area or a renal dialysis facilities.”renal dialysis facilities.”

Limitations for CoverageLimitations for Coverage

Medicare Part B covers KDE services.Medicare Part B covers KDE services.

1. Up to six (6) sessions as a beneficiary lifetime 1. Up to six (6) sessions as a beneficiary lifetime maximum. Session is 1 hour. In order to bill for a maximum. Session is 1 hour. In order to bill for a session, a session must be at least 31 minutes in session, a session must be at least 31 minutes in duration. A session that lasts at least 31 minutes, duration. A session that lasts at least 31 minutes, but less than one hour still constitutes 1 session.but less than one hour still constitutes 1 session.

2. On an individual basis or in group settings; if the 2. On an individual basis or in group settings; if the services are provided in a group setting, a group services are provided in a group setting, a group consists of 2 to 20 individuals who need not all be consists of 2 to 20 individuals who need not all be Medicare beneficiaries.Medicare beneficiaries.

Standards for ContentStandards for Content

The required content is divided into four categories.The required content is divided into four categories.

A. The management of comorbidities, including A. The management of comorbidities, including delaying the need for dialysis, which includes, but delaying the need for dialysis, which includes, but is not limited to, the following topics:is not limited to, the following topics:

1. Prevention and treatment of cardiovascular 1. Prevention and treatment of cardiovascular

diseasedisease

2. Prevention and treatment of diabetes2. Prevention and treatment of diabetes

3. Hypertension management3. Hypertension management

Standards for Content (cont.)Standards for Content (cont.)

4. Anemia management4. Anemia management

5. Bone disease and disorders of calcium 5. Bone disease and disorders of calcium

and phosphorous metabolism and phosphorous metabolism

managementmanagement

6. Symptomatic neuropathy 6. Symptomatic neuropathy managementmanagement

7. Impairments in functioning and well- 7. Impairments in functioning and well-

beingbeing

Standards for Content (cont.)Standards for Content (cont.) B. Prevention of uremic complications, which B. Prevention of uremic complications, which

includes, includes,

but is not limited to, the following topics:but is not limited to, the following topics:

1. Information on how the kidneys work and 1. Information on how the kidneys work and

what happens when kidneys failwhat happens when kidneys fail

2. Understanding if remaining kidney function 2. Understanding if remaining kidney function

can be protected, preventing disease can be protected, preventing disease

progression and realistic chances of survivalprogression and realistic chances of survival

Standards for Content (cont.)Standards for Content (cont.)

3. Diet restrictions 3. Diet restrictions

4. Medication review, including how each 4. Medication review, including how each medication works, possible side effects medication works, possible side effects

and minimization of side effects, the and minimization of side effects, the importance of compliance, and informed importance of compliance, and informed decision making if the patient decides decision making if the patient decides not to take a specific drugnot to take a specific drug

Standards for Content (cont.)Standards for Content (cont.)C. Therapeutic options, treatment modalities and C. Therapeutic options, treatment modalities and

settings, advantages and disadvantages of each settings, advantages and disadvantages of each treatment option, and how the treatments replace the treatment option, and how the treatments replace the kidney, including, but not limited to, the following:kidney, including, but not limited to, the following:

1. Hemodialysis - both at home and in-facility1. Hemodialysis - both at home and in-facility 2. Peritoneal dialysis (PD), including intermittent PD, 2. Peritoneal dialysis (PD), including intermittent PD,

continuous ambulatory PD, and continuous cycling continuous ambulatory PD, and continuous cycling

PD, PD, both at home and in-facilityboth at home and in-facility 3. All dialysis access options for hemodialysis and 3. All dialysis access options for hemodialysis and peritoneal dialysisperitoneal dialysis 4. Transplantation4. Transplantation

Standards for Content (cont.)Standards for Content (cont.) D. Opportunities for beneficiaries to actively participate D. Opportunities for beneficiaries to actively participate

in in the choice of therapy and be tailored to meet the the choice of therapy and be tailored to meet the

needs needs of the individual beneficiary involved, which includes, of the individual beneficiary involved, which includes,

but but is not limited to, the following topics:is not limited to, the following topics:

1. Physical symptoms1. Physical symptoms 2. Impact on family and social life2. Impact on family and social life 3. Exercise3. Exercise 4. The right to refuse treatment4. The right to refuse treatment 5. The impact on work and finances5. The impact on work and finances 6. The meaning of test results6. The meaning of test results 7. Psychological impact7. Psychological impact

Outcomes AssessmentOutcomes Assessment

“ “Qualified persons that provide KDE services Qualified persons that provide KDE services must develop outcomes assessments that are must develop outcomes assessments that are designed to measure beneficiary knowledge designed to measure beneficiary knowledge about CKD and its treatment. The assessment about CKD and its treatment. The assessment must be administered to the beneficiary during must be administered to the beneficiary during a KDE session, and must be made available to a KDE session, and must be made available to CMS upon request. The outcomes assessments CMS upon request. The outcomes assessments serve to assist KDE educators and CMS in serve to assist KDE educators and CMS in improving subsequent KDE programs, patient improving subsequent KDE programs, patient understanding, and assess program understanding, and assess program effectiveness of…”effectiveness of…”

Outcomes Assessment Outcomes Assessment (cont.)(cont.)

1. Preparing the beneficiary to make 1. Preparing the beneficiary to make informed decisions about their informed decisions about their healthcare options related to CKD.healthcare options related to CKD.

2. Meeting the communication needs 2. Meeting the communication needs of underserved populations, including of underserved populations, including persons with disabilities, persons with persons with disabilities, persons with limited English proficiency, and limited English proficiency, and persons with health literacy needs.persons with health literacy needs.

Objective TwoObjective Two

Discuss key components of Discuss key components of the CMS KDPE of particular the CMS KDPE of particular

interest to nephrology interest to nephrology nurses.nurses.

ComponentsComponents

Required contentRequired content

Presentation of contentPresentation of content

Outcome assessment toolsOutcome assessment tools

Required ContentRequired Content DiabetesDiabetes The most common cause of CKD world-wideThe most common cause of CKD world-wide

HypertensionHypertension More than 50 million Americans have hypertension More than 50 million Americans have hypertension

requiring treatmentrequiring treatment

Cardiovascular DiseaseCardiovascular Disease 10-20 times greater mortality in patients on dialysis10-20 times greater mortality in patients on dialysis

Required Content cont.Required Content cont.

Anemia Anemia Develops as early as stage 2Develops as early as stage 2 Contributes to development of LVH, CHF &Contributes to development of LVH, CHF & ischemic heart diseaseischemic heart disease

Bone and Mineral DisorderBone and Mineral Disorder Begins as early as stage 3Begins as early as stage 3

Diet and Fluid RestrictionDiet and Fluid Restriction

Required Content cont.Required Content cont.

Options:Options:

HemodialysisHemodialysis

Peritoneal dialysisPeritoneal dialysis

TransplantTransplant

HospiceHospice

Presentation of ContentPresentation of Content

Things to consider:Things to consider: DepressionDepression Short attention spanShort attention span Education levelEducation level DenialDenial Family supportFamily support LiteracyLiteracy

Outcome Assessment Tools Outcome Assessment Tools

Do not reinvent the wheel:Do not reinvent the wheel:

ANA, ANNA, NKF, RPA all have patient ANA, ANNA, NKF, RPA all have patient education information guidelines, education information guidelines, assessment tools and programs that assessment tools and programs that can be adapted to most topics.can be adapted to most topics.

Outcome Assessment ToolsOutcome Assessment Tools

Nephrology Nursing Journal, Mar/Apr2010, Vol. 37 Issue 2, p143-148, 6p, 1 chartChart; found on p146

Outcome Assessment Tools Outcome Assessment Tools (cont.)(cont.)

Reading LevelReading Level Written vs. pictorialWritten vs. pictorial OralOral Multiple choiceMultiple choice

Objective ThreeObjective Three

Critique of the CMS KDPE Critique of the CMS KDPE benefit.benefit.

HitHit

Funding for any patient educationFunding for any patient education Extensive content requirements Extensive content requirements Nephrology driven serviceNephrology driven service Adjusting reimbursement per RPAAdjusting reimbursement per RPA NP/CNS/PA involvementNP/CNS/PA involvement

MissMiss

Excluding RN’s from participationExcluding RN’s from participation Insufficient number of sessions Insufficient number of sessions Sessions too long for patient Sessions too long for patient

population attention spanpopulation attention span

Close…but no cigarClose…but no cigar

Starting education at CKD stage 4Starting education at CKD stage 4 Increased reimbursement but excludes Increased reimbursement but excludes

incident to billing for NP, CNS, PAincident to billing for NP, CNS, PA

BibliographyBibliography

AHRQ Stakeholders’. 2008. Executive Summary of Medicare AHRQ Stakeholders’. 2008. Executive Summary of Medicare Coverage of Kidney Disease Patient Education Services. Rockville, Coverage of Kidney Disease Patient Education Services. Rockville, MD.MD.

American Nephrology Nursing Association. American Nephrology Nursing Association. www.annanurse.orgwww.annanurse.org Counts, Caroline. (2008). Counts, Caroline. (2008). Core curriculum for nephrology nursingCore curriculum for nephrology nursing. .

2008-01. 2008-01.

Department of Health & Human Services. 2009. Pub 100-02 Department of Health & Human Services. 2009. Pub 100-02 Medicare Benefit Policy. Washington, D.C.Medicare Benefit Policy. Washington, D.C.

National Kidney Foundation. National Kidney Foundation. www.kidney.orgwww.kidney.org

Nephrology Nursing Journal. Mar/Apr2010, Vol. 37 Issue 2, p143-148.Nephrology Nursing Journal. Mar/Apr2010, Vol. 37 Issue 2, p143-148.

Renal Physicians Association. Renal Physicians Association. www.renalmd.orgwww.renalmd.org