September 24, 2004 The Honorable Mark McClellan, Administrator Centers for Medicare and Medicaid Services Room 445-G Hubert H. Humphrey Building 200 Independence Avenue, SW Washington, DC 20201 Re: CMS-1429-P; Comments on Revisions to Payment Policies under the Physician Fee Schedule for Calendar Year 2005; Proposed Rule Dear Administrator McClellan: The American Nephrology Nurses Association (ANNA) thanks you for the opportunity to provide the Centers for Medicare and Medicaid Services (CMS) with comments about the Proposed Rule for the Calendar Year 2005 Physician Fee Schedule (Proposed Rule). ANNA is a professional organization representing some 11,000 nephrology nurses whose main patient population is the hemodialysis population. ANNA is a member of the Kidney Care Partners (KCP) and these comments should be considered as additional to their response and not in conflict. We have four areas of specific interest: Nephrology nurses love what they do best direct patient care. Our concern with the financial aspects of this rule is that there will be a net reduction in the overall reimbursement for the dialysis treatment and dialysis related drugs that will impact decisions that are made by providers and that this, in turn, will further exacerbate the recruitment and retention of qualified, experienced nurses into our specialty to work in dialysis units. Because dialysis facilities lack an annual update, we are challenged to compete with hospitals that can offer nurses so much more in terms of appropriate workload, training, administrative support as well as salary. Nephrology nurses want to be appropriately compensated but we value even more the benefits of having proper training and experienced supervision of all the staff. It is the stress of not having these, if reimbursement is compromised, that make new nurses leave and more experienced nurses move to positions that have less liability and stress attached.The venous mapping rule should be revised to include arterial studies because it has been clearly shown through the work of leaders in the National Vascular Access Improvement Initiative (Fistula First) that at times arterial studies are necessary to ensure the success of fistula creation. We therefore suggest renaming the studies vascular mapping. We further recommend that reimbursement for these studies be extended to nephrologists and interventional radiologists who frequently perform the studies prior to surgical creation of the fistula.We applaud the expansion of the telehealth services to include the monthly management visits for dialysis patients with end-stage renal disease (ESRD). As proposed, ANNA supports the standard that every ESRD dialysis patient have a face-to-face comprehensive assessment as part of their monthly care plan. This face-to-face visit can be completed by either a physician or practitioner (nurse practitioner, clinical nurse specialist, or physician assistant). The other 2 to 3 monthly visits could be made either in-person or electronically, with an inexpensive interactive audio and video telecommunications system which are now readily available commercially. We support the proposed new G-codes for ESRD-related services to be added to the list of telehealth services. To meet the August 5, 2004 NRPM regarding ESRD patients, nephrologists and practitioners (NPs, CNSs, and PAs) would complete the once a month comprehensive in-person visit to the ESRD patient. The other 2 or 3 monthly visits could be completed by setting up a satellite office in a distant dialysis facility, and completing telehealth visits via telecommunications technologies for an audio and video-conference. We have detailed, cost-effective suggestions for the equipment and procedure for the additional visits that we would be pleased to forward to you.In addition to the inclusion of nurse practitioners in the rule on telehealth, we trust that nurse practitioners will be included in all areas that describe physicians as medical care providers. We believe that nurse practitioners in collaboration with nephrologists provide high quality care to the hemodialysis patient care population. Indeed it is our sincere hope that when ESRD Disease Management is a reality for all hemodialysis patients that nurse practitioners will play an integral role in the day to day management of this patient population. ANNA members sincerely appreciate your request for, and review of, our input into this most important rule. We hope that you will not hesitate in contacting us if you have questions regarding these comments (Lesley Dinwiddie, 919- 859-0994) or if we can be of any help in the future. Sincerely, Lesley Dinwiddie, MSN, RN, FNP, CNN President American Nephrology Nurses' Association  69 Fed. Reg. 47488 (2004).