Intensive dietary interventions in patients with chronic kidney disease (CKD) has been controversial in the United States. It is interesting to note that even though evidence abounds on the effectiveness of dietitian interventions and government money is available for these services, patients are not receiving them.
Evidence demonstrating the effectiveness of dietitian-led internventions is reflected in two well-designed studies by Brunori et al (Am J Kidney Dis 49:569-580) and Campbell et al (Am J Kidney Dis 51:748-758). The study by Brunori et al demonstrated that patients with end-stage renal disease (ESRD) who were trained by dietitians on how to follow very low protein diets and to use keto acid supplementation had better nutrition status and longer survival than the ESRD patients who started dialysis. Similarly, Campbell et al showed less body cell mass loss, increased energy intake, and greater improvement in subjective globabl assessment with intensive dietitian intervention when compared with usual care in patients with CKD stages 4 and 5. Results of a meta-analysis by the Cochrane Library revealed that non-diabetic patients with CKD had a 32% decreased relative risk of death when following a low protein diet compaerd with a high protein diet (Fouque D, Laville M. Cochrane Database of Systematic Reviews 2009;8(3).
Dietitian involvement uncommon
Beginning in January 1, 2002, under Medicare Part B, Medical Nutrition Therapy (MNT) for diabetes and kidney disease became a covered service for beneficiaries when referred by a physician. Unfortunately, according to a new report (Am J Kidney Dis 2011;58:583-590) only 10.5% of patients who initiated dialysis in 2005 had previously been seen by a dietitian for CKD. Between 2005 and 2007, 88% of the patients had not received care by a dietitian at all, 9 % had received care for 12 months or less, and 3% had received care for 12 months or more. Interestingly, those patients who were seen by a dietitian for more than 12 months had a 19% relative risk reduction for death.
So why are CKD patients not being seen by registered dietitians? It may be that once the patient has been diagnosed they are continuing to be followed by a primary care physician who may be unaware of the importance of dietary care. According to the 2010 U.S. Renal Data System report, patients on Medicare have a 0.93 probability of being seen by a primary care physician 12 months after diagnosis but only a 0.31 probability of being seen by a nephrologist. Therefore, it may be beneficial to educate primary care physicians about Medicare reimbursement for MNT treatment and the potential impact of seeing a dietitian on mortality rates for CKD patients.
Qualifying for reimbursement
Additionally, dietitians themselves may not be familiar with the process of receiving reimbursement for MNT in CKD patients. To qualify for reimbursement by Medicare the patient must have one of the following three diagnoses: type 1, type 2, or gestational diabetes; CKD pre-dialysis or ESRD pre-dialysis; or recipient of a renal transplant whereby the patient is cared for in the outpatient setting 6-36 months post-transplant. Services can be provided to individual patients or groups of patients, but the dietitian must be registered and licensed in the state where the services will be provided.
The number of hours covered in an episode of care, within a 12 month period, cannot be exceeded. For a patient who has been newly diagnosed with CKD prior to dialysis, the number of hours is three per a 12 month period. Within the three hours, both assessment and follow-up care for nutrition intervention should occur.
To receive reimbursement for services registered dietitians must apply to become a Medicare provider. Additionally, the dietitian should explore whether coordination of billing codes (see table 1) and assignment of reimbursement can be done through their medical facility. Finally, a standard referral form for physician use should be developed since reimbursement will only occur if the patient is referred to the dietitian by a physician. The rate of reimbursement fluctuates annually and geographically, so dietitians should determine the rate in the state in which they provide services.
The National Kidney Foundation Kidney Disease Outcomes Quality Initiative evidence-based guidelines recommend monitoring of nutritional status every 6-12 months for patients with stage 3 CKD and one to three months for patients in stage 4 and 5 pre-dialysis. In this case, the evidence supports these guidelines and the government has provided the funding to enact them. Now it is time for the physicians and dietitians to work together to ensure CKD patients receive the care they need.
Dr. Steiber is Coordinator of the Dietetic Internship/Master’s Degree Program at Case Western Reserve University in Cleveland.