Using Physician Extenders to Create a CKD Clinic: Using Physician Extenders to Create a CKD Clinic Theresa Becker, MSN, APNP Midwest Nephrology Assoc. Chronic Kidney Disease Clinic


CKD Clinic: CKD Clinic The ideas of: Linking CKD Clinics & Anemia Management Programs Using physician extenders in a multidisciplinary approach Are not new!


CKD Clinic: CKD Clinic ADEPT Clinic Arizonia Disease Education Prevention & Treatment Started as an anemia management clinic but soon developed into a CKD Clinic Patients are referred to the Vascular Access Program when GFRs are 25-30 mL/min. Curtis C, Yee B. The process of implementing a CKD Clinic Nephrology News & Issues. 2005;19:53-54.


CKD Clinic: CKD Clinic SHAPE UP Program Staging & Smoking Cessation Hypertension, Hyperglycemia, Hyperlipidemia, Hyperphosphatemia, Hyperparathyroidism, Hyperkalemia, & Hypervolemia Anemia Proteinuria Evaluation for KRT Undo nephrotoxins Preservation of veins & Patient education Gnanasekaran I, Kim S, Dimitrov V, Soni A. SHAPE UP-A management program for chronic kidney disease Dialysis & Transplantation. 2006;35: 294-302.


CKD Clinic: CKD Clinic One step further : A study by Curtis et al. suggested that even after appropriate & timely referral to a nephrologist, there is additional value of a multidisciplinary team approach in optimizing both short and long term patient outcomes. Curtis BM, Ravani P, Malberti F, et al. The short and long term impact of multi- disciplinary clinics in addition to standard nephrology care on patient outcomes. Nephrol Dial Transplant. 2005;20:147-154.


CKD Clinic: CKD Clinic Midwest Nephrology Associates CKD Clinic Model


CKD Clinic: CKD Clinic Components of the CKD Care Plan GFR < 60 ml/min. HTN Anemia Nutritional Status/DM Bone/Mineral Metabolism Neuropathy Functioning & Well-being Delaying Progression of CKD


CKD Clinic: CKD Clinic Components of the CKD Care Plan GFR < 30 ml/min. Review Modality Options Preparation for chosen option Transplant referral GFR < 15 ml/min. Tour Clinic Monitor for ESRD signs & symptoms


CKD Clinic: CKD Clinic CKD Patient Education Topics CKD and consequences; anemia and bone disease Common medications used in CKD Avoidance of nephrotoxic agents KRT Modalities Arm Preservation for HD access, Access placement & care of site Healthy living


CKD Clinic: CKD Clinic Access Teaching Pre AV access: Evaluation for appropriate arm such as vein mapping and instruction on saving that arm. Post AV access: Care of the site, exercising the access, and monitoring its development as well as instruction on its future use.


CKD Clinic: CKD Clinic Documentation Medication List Clinical Action Plan Health Maintenance Clinic Note Surgical Referral Form Vascular Access Record Chart Label


CKD Clinic: CKD Clinic Surgical Referral Form Date: __________________ Surgeon: __________________________ Phone: ______________ Fax: ________________ Patient: _________________________________________________ DOB: _______________ Nephrologist: ________________________ Phone: ______________ Fax: _______________ PCP: ______________________________ Phone: _______________ This patient is being referred to you for access placement. The desired access is an AV Fistula. In the event you are not planning to place an AV Fistula in this patient, please call the nephrologist prior to placing any other access. Patient’s non-dominant are is:  Right  Left Patient has been saving the following arm:  Right  Left Comments (ie: arm injury/mastectomy/pacemaker/previous access): Vein Mapping done pre-referral:  No  Yes – Date/Location: ______________________ Patient is currently on dialysis: Days: ____________________________________________________________________ Location/Phone: ____________________________________________________________ Patient is not on dialysis at this time: Anticipated hemodialysis start date: _______________________ months Most recent serum creatinine: ________ mg/dL & Creatinine Clearance/GFR: ________ ml/min Patient is on Anti-Coagulant Therapy:  No  Yes ___________________________________ Allergies:  NKDA  Yes _______________________________________________________ The following patient information is also enclosed:  Face Sheet  Vein Mapping Report  H & P  Recent Labwork  Medication List


CKD Clinic: CKD Clinic Vascular Access Record Stage 4 (GFR 65% for prevalent patients.


CKD Clinic: CKD Clinic Surgeon ___________________ Date _______________


CKD Clinic: CKD Clinic


CKD Clinic: CKD Clinic Chart Label


CKD Clinic: CKD Clinic AVF Statistics Patients Initiating HD 1/1/06 to 10/31/06


CKD Clinic: CKD Clinic Vaccination Statistics 7/1/06 to 12/31/06


CKD Insurance Issues: CKD Insurance Issues CPT Office Visit Billing Codes Low complexity visit (~ 15 min.) – 99213 Moderate complexity visit (~ 25 min.) – 99214 High complexity visit (~ 40 min.) – 99215


CKD Insurance Issues: CKD Insurance Issues ICD 9 Office Visit Billing Codes CKD Stage 1 (GFR > 90) – 585.1 CKD Stage 2 (GFR 60-89) – 585.2 CKD Stage 3 (GFR 30-59) – 585.3 CKD Stage 4 (GFR 15-29) – 585.4 CKD Stage 5 (GFR<15) – 585.5


CKD Insurance Issues: CKD Insurance Issues Office Visit Reimbursement Commercial Insurances reimburse NPs at 100% of MD charges Medicare only reimburses NPs at 80% of MD charges Medicare and a secondary insurance reimburses NPs at 100% of MD charges


Anemia Management Program : Anemia Management Program Erythropoietin Stimulating Agents (ESA) Available for Stage 1 – 5 CKD Patients McClellan, Schoolwerth A., Gehr, T. Clinical Management of Chronic Kidney Disease. Cadido, OK: Professional Communications, Inc.; 2006:185-208.


ESA Agents: ESA Agents Aranesp Package Insert Amgen®


ESA Agents: ESA Agents Side Effect Profile HTN and Headaches Myalgias Diarrhea Contraindications Uncontrolled HTN Known hypersensitivity to the active substance or any of the excipients


ESA Agents: ESA Agents FDA Black Box Warning Issued 3/9/07 Use the lowest dose of ESA that will gradually increase the Hgb concentration to the lowest level sufficient to avoid the need for RBC transfusion. ESAs increase the risk for death and serious CV events when administered to target a Hgb > 12 gm/dL.


ESA Agents: ESA Agents RPA Renal Physicians Association Risks and benefits must be on individual patient basis Evidence based Hgb targets are helpful and should be reintroduced May lead to unacceptably low Hgb levels AAKP American Association of Kidney Patients Warning may be confusing to patients & providers Supports targeting Hgbs between 11 and 12 Lower Hgb lead to concerns regarding QOL


ESA Agents: ESA Agents Epoetin alfa (Procrit) Single-Dose Preservative Free Vials 2,000 units, 3,000 units, 4,000 units, 10,000 units, 40,000 units/1 mL Multi-Dose Preserved Vials 20,000 units/1 mL 20,000 units/2 mL


ESA Agents: ESA Agents Darbepoetin alfa (Aranesp) Single-Dose Preservative Free Vials 25 mcg, 40 mcg, 60 mcg, 100 mcg, 200 mcg, 300 mcg, 500 mcg/1 mL 150 mcg/0.75 mL


ESA Agents: ESA Agents Darbepoetin alfa (Aranesp) Single-Dose Prefilled Syringes 25 mcg/0.42 mL 40 mcg/0.4 mL 60 mcg/0.3 mL 100 mcg/0.5 mL 150 mcg/0.3 mL 200 mcg/0.4 mL SingleJect Syringe SureClick Syringe


ESA Utilization Guidelines: ESA Utilization Guidelines Hgb Level of < 11.0 gm/dL within 30 days T. Sat. and/or Ferritin within 30 to 90 days Serum creatinine within 30 days Patient’s weight in kilograms ESA Dose per kilogram Erythropoietin level is NOT recommended


ESA Utilization Guidelines: ESA Utilization Guidelines Target Hgb at or above 11.0 gm/dL Caution when intentionally maintaining Hgb > 13.0 gm/dL Monitor Hgb minimum of every 30 days Target Ferritin > 100 ng/mL and T. Saturation > 20% Monitor Iron Indices Quarterly


ESA Utilization Guidelines: ESA Utilization Guidelines Dose Adjustments If Hgb increases by > 2 gm/dL per 4 weeks and/or Hgb level > 12 gm/dL, decrease dose by 20 to 25% If Hgb level is increasing < 1 gm/dL per 4 weeks, increase dose by 20 to 25%


ESA Utilization Guidelines: ESA Utilization Guidelines Dose Adjustments 20 to 25% dose adjustments may be achieved by: Altering the ESA dose Altering the time interval between injections


ESA Utilization Guidelines: ESA Utilization Guidelines Dose Adjustments Increases in dose should not be made more frequently than once a month. Avoid holding doses to avoid marked drop in ESA sensitive RBC precursors and the ‘seesaw’ effect of Hgb poor response pattern.


ESA Utilization Guidelines: ESA Utilization Guidelines Dose Adjustments More frequent Hgb &/or iron indices monitoring may be necessary when: Recent bleeding or surgery Post hospitalization Post IV iron course Periods of ESA hypo-response


ESA Utilization Guidelines: ESA Utilization Guidelines ESA Resistance Infection/Inflammation Blood Loss, Guiac Positive Stools Hyperparathyroidism B12, Folate Deficiencies Sickle cell, Thalacemias Multiple Myeloma/Malignancy ACE Inhibitor Use


ESA Utilization Guidelines: ESA Utilization Guidelines Dose Adjustments Recent data indicates Hgb levels can be maintained with every two week epoetin alfa dosing and monthly darbepoetin alfa dosing. Benefits include increased staff productivity and patient satisfaction/compliance. Moore T., Chookie S. Extended dosing od darbepoetin alfa in patients with chronic kidney disease not on dialysis: A review of recent data. Journal of ANNA 2005;32:399-407.


ESA Utilization Guidelines: ESA Utilization Guidelines Medicare considers doses exceeding 90,000 units per week for epoetin alfa or 200 mcg per week for darbepoetin alfa to be rarely reasonable and necessary. Medical justification for doses exceeding these amounts should be documented in the patient’s record.


ESA Utilization Guidelines: ESA Utilization Guidelines ESA Flowsheet


Hemoglobin Monitoring : Hemoglobin Monitoring HemoCue vs. Lab Draw HemoCue Analyzer utilizes an optical measuring microcuvette. It provides nearly instantaneous Hgb results with very good accuracy. Traditional Lab Draw may be used. However, it will require another appointment or extended patient visit while awaiting lab results.


Hemoglobin Monitoring: Hemoglobin Monitoring HemoCue Analyzer HemoCue Inc. 40 Empire Drive Lake Forest, CA 92630 Phone: 1800.881.1611 Fax: 1800.333.7043 www.hemocue.com HemoCue machines require a CLIA (Clinical Laboratory Improvement Amendment) Certificate of Waiver www.cms.hhs.gov/clia/


ESA Insurance Issues: ESA Insurance Issues CPT ESA Billing Codes Epoetin alfa – J0885 (Standard unit 1,000 units) Darbepoetin alfa - J0881 (Standard unit 1 mcg) Injection – 90772 HemoCue Lab – 85018QW


ESA Insurance Issues: ESA Insurance Issues ICD 9 ESA Billing Codes Anemia – 285.9 CKD Stage 1 (GFR > 90) – 585.1 CKD Stage 2 (GFR 60-89) – 585.2 CKD Stage 3 (GFR 30-59) – 585.3 CKD Stage 4 (GFR 15-29) – 585.4 CKD Stage 5 (GFR<15) – 585.5


ESA Insurance Issues: ESA Insurance Issues Benefit Determination Billing Office Review of Patient’s Insurance Procit – PROCRITline 1800.553.3851 or www.procritline.com Aranesp – Amgen Reimbursement Connection 1800.272.9376 or www.reimbursementconnection.com


ESA Insurance Issues: ESA Insurance Issues Benefit Assistance HealthWell Foundation P.O. Box 4133 Gaithersburg, MD 20885-4133 Phone: 1800.675.8416 Fax: 1800.282.7692 www.healthwellfoundation.org


ESA Insurance Issues: ESA Insurance Issues Drug Assistance Drug company vouchers which generally allow one month supply of ESA ESA samples may be available


ESA Self Administration: ESA Self Administration Initial Teaching ESA script must include Anemia & CKD Stage ICD 9 codes Instruct patient on storage, handling, and observe administration of ESA Office visit charge


ESA Self Administration: ESA Self Administration Monitoring Monthly HemoCue lab charge vs. traditional lab draw Office visit charge


New Agents: New Agents Mircera Developed by Roche First and only Continuous Erythropoietin Receptor Activator (C.E.R.A.) Twice monthly dosing schedule, however generally will be able to administer monthly yet maintain stable Hgb levels IV/SC administration May be used in CKD & dialysis patients


IV Iron: IV Iron Iron Sucrose (Venofer) 100 mg/1 mL vial Administer 200 mg slow IV infusion over 2 to 5 minutes on 5 different occasions within a 14 day period. Typically dosed weekly for 5 weeks. Generally administered when Ferritin < 100 ng/mL and/or T. Saturation < 20%


IV Iron Insurance Issues: IV Iron Insurance Issues CPT Iron Billing Code Iron Sucrose – J1786 (Standard unit 1 mg) IV Infusion – 90765 Office charge, high complexity visit - 99215 ICD 9 Iron Billing Code Iron Deficiency Anemia – 280.9


Questions: Questions