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Acute Kidney Injury Care and Incentive Changes for Year 2020

January 7, 2020

Nephrology-CodingThere have been a few changes in Nephrology Coding for year 2020 – the way acute kidney injury care gets covered, methods of documenting E&M services, and the merit-based incentive payment system this year. These changes come from the release of the 2020 fee schedule final rule, which was released in November, although any comments on that rule should be submitted by December 31, 2019 (although it is doubtful anything in the final rule will change). 

Changes to the Way Acute Kidney Injury Care is Covered

Within the Physician Fee Schedule final rule released in November, there was some excellent news for nephrologists. CMS finalized their earlier proposals to allow Most of the dialysis codes, adult, pediatric, outpatient, and inpatient are seeing increases that range between 0.1% and 1.0% – except for the adult daily dialysis code 90970, which increased by 4.5%. There has also been an increase of 0.8% for the adult in-center, four-visit CPT code 90960, as well as a 0.4% bump for hemodialysis, single evaluation (code 90935).

When it comes to interventional dialysis services, two of the high volume dialysis circuit codes saw some changes. There’s a 3.0% increase for thrombectomy with angioplasty (CPT 36905 and a 2.5% bump for angioplasty (CPT 36902) when patients receive these services within the physician’s office.

Another piece of positive news for the nephrology field is that the final decision was made by CMS allowing transitional care management (TCM) codes (the CPT codes 99496 and 99495) to be billed with adult outpatient dialysis codes (including CPT codes 90970, 90969, 90966, 90962, 90961). In the past, billing TCM codes for end-stage renal disease patients were not allowed. Now, when nephrologists follow patients post-discharge, provided they comply with requirements of the TCM codes like documentation, Medicare can be billed. Reimbursement for CPT code 99495 for 14-day post discharge will be $187.67, and reimbursement for CPT code 99496, which is used for 7-day post discharge, is $247.93.

Changing Methods of Documenting E&M Services

Currently, CMS has abandoned plans to completely restructure E&M coding to collapse payment amounts of higher-level codes into one level – something that would have potentially disproportionately affected nephology payments – although those changes are still slated for 2021. However, while this plan is currently on hold, there have been some changes to the methods of documenting E&M services that nephrology practices must be aware of in the coming year.

Proposals to reduce the E&M documentation burden for physicians was were also finalized in the November release of the final rule, which is also expected to be carried out in 2021. When it goes into effect, the following changes will occur:

  • Discontinuation of the “bullet point” method of documenting any E&M services, since CMS calls this “clinically outdated.”
  • Physical and history documentation only must reflect things that are medically appropriate.
  • When clinicians choose to use time as their basis for billing, they can include the total time that is spent on the day of the patient visit (including both face-to-face as well as non-face-to-face time), allowing time spent on the patient both before and after the face-to-face patient interaction to be included in the billing.

Merit-Based Incentive Payment System Changes

Unfortunately, for nephrology practices, the final rule includes some negative news as well. Along with the final rule came the complete elimination of nephrology-specific performance measures that come with the merit-based incentive payment system (MIPS). There will also be an episode-based quality measure for the acute kidney injury patients that require new inpatient dialysis. Both of these proposals have been opposed by the Renal Physicians Association.

According to the Renal Physicians Association’s director of public policy, Robert Blaser, these proposed rules have “…highlighted our concern that the rate at which such changes are being proposed and implemented is counter to CMS’ own goals,” Blaser wrote in his analysis. “RPA stated that the [quality payment program] QPP must be allowed to mature, and dramatic changes as proposed with the elimination of specialty-specific measures and the development of the MIPS value pathways (MVPs) are premature. Furthermore, continually changing the program has increased provider burden, and potentially burnout, by requiring time away from patients to study changes and implement new workflows, rather than allowing providers the space to understand and comply with the existing components of the QPP.”

The president of RPA went on to say that he felt that moving more to primary care-centric measures and the changes to MIPS would be detrimental to kidney patient care. To ensure improved quality of care for patients suffering from kidney disease, nephrologists do need to be measured by relevant, clinically meaningful, and specific measures.

Despite the many objections coming from the medical community, the following measure that are specific to the nephrology specialty have been eliminated from MIPS:

  • MIPS 329 for Adult Kidney Disease – Catheter use at any hemodialysis initiation
  • MIPS 403 for Adult Kidney Disease – A referral to hospice
  • MIPS 328 for Pediatric Kidney Disease – ESRD Patients Receiving Dialysis – Hemoglobin levels that are less than 10 g/dL
  • MIPS 330 for Adult Kidney Disease – Catheter use for 90 or more days

As you enter the new year and begin to focus on increasing your bottom line, ensure your nephrology practice is currently on the changes and aware of the additional changes likely coming in 2021. If you need help ensuring that your practice is maximizing per code collection and preventing costly denials, we can help. M-Scribe specializes in medical coding, payer contract review, and more, and we’re here to help your nephrology practice succeed in 2020. Contact us today at for more information on how we can help your nephrology practice.

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