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Using Physician Extenders to Create a CKD Clinic. Theresa Becker, MSN, APNP Midwest Nephrology Assoc. Chronic Kidney Disease Clinic. CKD Clinic. The ideas of: Linking CKD Clinics & Anemia Management Programs Using physician extenders in a multidisciplinary approach Are not new!.

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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 clinic3
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 clinic4
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 clinic5
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 clinic6
CKD Clinic

Midwest Nephrology Associates CKD Clinic Model

ckd clinic7
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 clinic8
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 clinic9
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 clinic10
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 clinic11
CKD Clinic


  • Medication List
  • Clinical Action Plan
  • Health Maintenance
  • Clinic Note
  • Surgical Referral Form
  • Vascular Access Record
  • Chart Label
ckd clinic12
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 clinic13
CKD Clinic

Vascular Access Record

Stage 4 (GFR < 30 ml/min): Surgical consult should be for ‘AVF Only’.

  • Instruct Patient to Preserve Veins of Non-Dominant or Appropriate Arm
  • Obtain Vein Mapping
  • KDOQI Benchmark: AVF placement of > 65% for prevalent patients.
ckd clinic14
CKD Clinic

Surgeon ___________________ Date _______________

ckd clinic16
CKD Clinic

Chart Label

ckd clinic17
CKD Clinic

AVF Statistics

Patients Initiating HD

1/1/06 to 10/31/06

ckd clinic18
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 issues20
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 issues21
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 agents24
ESA Agents

Side Effect Profile

  • HTN and Headaches
  • Myalgias
  • Diarrhea


  • Uncontrolled HTN
  • Known hypersensitivity to the active substance or any of the excipients
esa agents25
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 agents26

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


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 agents27
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 agents28
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 agents29
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 guidelines31
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 guidelines32
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 guidelines33
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 guidelines34
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 guidelines35
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 guidelines36
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 guidelines37
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 guidelines38
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.

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 monitoring41
Hemoglobin Monitoring
  • HemoCue Analyzer

HemoCue Inc.

40 Empire Drive

Lake Forest, CA 92630

Phone: 1800.881.1611 Fax: 1800.333.7043

  • HemoCue machines require a CLIA (Clinical Laboratory Improvement Amendment) Certificate of Waiver

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 issues43
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 issues44
ESA Insurance Issues

Benefit Determination

  • Billing Office Review of Patient’s Insurance
  • Procit – PROCRITline

1800.553.3851 or

  • Aranesp – Amgen Reimbursement Connection

1800.272.9376 or

esa insurance issues45
ESA Insurance Issues

Benefit Assistance

  • HealthWell Foundation

P.O. Box 4133

Gaithersburg, MD 20885-4133

Phone: 1800.675.8416

Fax: 1800.282.7692

esa insurance issues46
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 administration48
ESA Self Administration


  • Monthly HemoCue lab charge vs. traditional lab draw
  • Office visit charge
new agents
New Agents


  • 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