Continuous Renal Replacement Therapy: Cost Considerations and Reimbursement

CONTINUOUS RENAL REPLACEMENT THERAPY

Continuous Renal Replacement Therapy: Cost Considerations and Reimbursement

Luz Moreno, Robert J. Heyka, and Emil P. Paganini Department of Nephrology and Hypertension, The Cleveland Clinic Foundation, Cleveland, Ohio

The costs associated with continuous renal replacement therapy (CRRT) vary from center to center, and depend upon personnel, technical support, supplies, methods of anticoagulation, CRRT modality and patient population (Table 1). Selection among the options available (and evaluation of cost considerations) becomes more complex when CRRT is compared with intermittent hemodialysis (IHD) or acute peritoneal dialysis (APD). Thus what follows is, of necessity, a highly individualized approach to the subject of cost of CRRT. We have calculated an experience-based cost of CRRT and compared that to costs for IHD and APD. Others have reported on similar comparisons (1-4). We hope that this information will be useful to individual dialysis centers and will initiate discussions which facilitate a more standardized approach in the future.

A center that does not currently have a CRRT program, but is considering one, needs to include cost in the decision-making process. Start-up strat- egies that we have found useful in assisting other centers include: 1. identify key people in decision-making, 2. delineate responsibilities such as setup, monitor-

ing and maintenance of the equipment, as well as off-hour and weekend coverage,

3 . simplify techniques, policies and procedures, and 4. provide continuous education of personnel. Once responsibilities and policies are defined, the costs can be calculated. For example:

0 who are the personnel responsible for machine

how often will tubing and dialyzers be

who will monitor the equipment and who is

In our experience, the renal service based CRRT intensive care unit (ICU) nurse coordinator has become an invaluable team member, enhancing our interaction with medical and surgical services involved in the ICU, orienting and training new ICU staff, and providing quick answers to questions to

and software setup and maintenance?

changed?

responsible on weekends and evenings?

allay fears and increase acceptance of the CRRT program.

Cost Comparison

In order to compare the different dialytic modalities, cost was divided into that of basic equipment and supplies to start the treatment and ongoing cost of delivering dialytic support over a one week period. The costs of basic equipment and supplies for initiation of CRRT are listed in Tables 2 and 3 . For calculations, we used retail prices from two different vendors. While arterial-based CRRT does not require a machine, low pressure CRRT (i.e., venovenous) necessitates the purchase of a pumping system. The estimates for IHD do not include any additional expenses for water treatment equipment when treated water is not available in the ICUs. Minimum requirements would be for one or more stationary or portable units with a carbon filter and a reverse osmosis membrane. Individual centers will differ in their approaches to water treatment needs.

Customarily, IHD prescription consists of 3 to 4 hour sessions, three times a week and CRRT rates of l l h o u r . This implies higher clearances delivered by CRRT (5 ) . The usual IHD prescription provides a urea clearance of 10-12 mllmin. Therefore, to compare the cost of delivering equivalent clearances we calculated the expenses of delivering 10

TABLE 1. Factors in the cost of CRRT Equipment Filters, lines, access, IVAC's, catheters,

machines (CVVH, CVVHD, IHD, APD), volumetric pumps, water treatment system, preventive maintenance, depreciation

Dialysate (Dianeal Vs On line dialysate), replacement solution, anticoagulation (Heparin, low molecular weight heparin, citrate), type of dialyser (hollow-fiber, plate biocompatibility) and frequency of replacement

Fellows.

Supplies

Personnel Coordinator, technicians, LPNs, RNs,

Modality Arterial vs. venous, hemofiltration v. hernodialysis, continuous v. intermittent, peritoneal v. hemo-based, pre v. post dilution, ultrafiltration and dialysate rates

ECMO, LVAD, sepsis, MOF, post transplant,

Address correspondence to: €mil P. Paganini MD, Dept of Ne- phrology und Hypertension, The Cleveland Clinic Foundation, 9500 Euciid Ave, Cieveland, Off 44195 Seminars in Dialysis-Vol 9, No 2 (Mar-Apr) 1996 pp 209-214

Special situations bums, pediatric

209

210 Moreno et al.

TABLE 2. Cost* of basic equipment and supplies for initiation of therapy

IHD PD CVVH, CVVHD, CAVH, CAVHD, CVVHDF, CVVU CAVHDF, CAVU Modality

Dialysis machineblood pump 8000 to 9000 0 14Ooo to 2 m . 6Ooo to loo00 Catheter and placement kit 40 to 80 40 to 110 40 to 80 100 to 200 Filters 20 to 30 20 to 100 20 0 Blood lines 20 to 30 10 to 20 S 0 Total 8080-92 10 70-230 14065-201 05 6 100-10200

* The costs are presented in U.S. dollars. CVV = Continuous venovenous; CAV = Continuous arteriovenous; H = Hemofiltration; HD = Hemodialysis; HDF = Hemo-

diafiltration; U = Ultrafiltration; IHD = Intermittent hemodialysis; PD = Peritoneal dialysis.

TABLE 3. Per liter cost* of replacement and dialysate solution ultrafiltrate for CVVHD-CAVHD. It should be Replacement Solutions Dialysate Solutions

Made by Lactate or 1.5% Dianeal On line pharmacy saline (Baxter) dialysate

15 to 30 1 to 2 2 to 3 1 to 2 * The per liter costs of replacement and dialysate solutions are

presented in U.S. dollars.

mL/min of urea clearance per day with the different types of therapy. Results are shown in Table 4. In- termittent hemodialysis, PD, and ultrafiltration are included for comparison. Averaged cost over a one week period of delivering 10 mL/min and 15 mL/ min of urea clearance is presented in Table 5.

To obtain a 10 mL/min clearance, the following assumptions were made: 1 three sessions a week, 3-% hours each, with a

blood flow of 275-300 mL/min. and an effective clearance of approximately 170 mL/min for IHD,

2 ten 2-liter volume exchanges with 1.5% Dianeal on a daily basis for APD,

3 replacement solution rates of 600 mL/hour for CVVH and CAVH,

4 a dialysate solution rate of 500 m u o u r plus 100 m U hour of ultrafiltrate for CVVHD and CAVHD, and

5 a single filter change per day for CRRT. For increased clearance at 15 mL/min, we assumed 4 instead of 3 IHD sessions per week, 15 exchanges of 2-liter volume daily for PD (higher volumes will not be possible in ICU patients with concerns of adequate ventilation), as well as replacement solution rates of 900 mL/hour for CVVH-CAVH and dialysate rate of 800 mL/hour with 100 mL/hour of

noted that miscellaneous equipment, preventive maintenance and depreciation of equipment are not factored into this comparison.

The clinical issues most importantly associated with the generation of cost for any therapy are: (a) consumable materials ; (b) personnel requirements; (c) frequency of services replacement; and (d) type of service rendered. These considerations are ge- neric to all extracorporeal therapy delivery and should be of prime importance in evaluating a program for cost effective improvement.

Basic dialytic mechanics will demonstrate a much better urea control with dialysis over hemofiltration (6) . Diffusion indeed is more effective with molecules of smaller size, whereas larger molecules are more influenced by convection. As our model shows, increasing the urea clearance will require improving the characteristics of diffusion or increasing the exchanges of filtration, both increasing the cost. However, increasing the flow of dialysate for flow dependant factors will be more rewarding than increasing the hemofiltration exchange. Also, the dialysate need not be sterile, while the hemofiltration replacement solution does. This difference will carry a strong financial consequence when one begins to compare the basic cost of the fluid involved.

If the model were attempting to increase larger (“membrane dependent”) molecular transfer, then either an increase in hemofiltration rates or an addition of limited hemofiltration to a diffusive dialysis system would be most appropriate. This latter form of therapy (hemodiafiltration) will carry both the added expense of hernofiltration and the cost effectiveness of hemodialysis.

Table 4. Daily cost* of maintaining CRRT providing a urea clearance of 10 mLlmin

Modality CVVH, CAVH CVVHD, CAVHD CVVU, CAVU IHD PD Filterslday 100 15-100 15-100 20 0 Pharmacy made solution 216-432 (15 L) 0 0 0 0 Lactated ringer 15-30 (15 L) 0 0 0 0 Dineal 1.5% 24-36 (12 L) 0 4060 (10 L) On line bicarbonate solution 0 0 0 12 (120 L) 0 Nurse’s fee 0 0 0 72 (4h) 0 Technical fee 30 30 30 0 30 Catheter kit 0 0 0 42-78 0 Total (approximated) 150-560 70-170 50-130 150-180 70-90

* Costs are presented in U.S. dollars. CVV = Continuous venovenous; CAV = Continuous arteriovenous; H = Hemodiltration; HD = Hemodialysis; U = Ultrafiltra-

tion; IHD = Intermittent hemodialysis; PD = Peritoneal dialysis.

COST OF CRRT 211

Table 5. Weekly cost* of maintaining CRRT providing a urea clearance of 10 rnL/min and 15 mL/min

Modality CVVH, CAVH CAVHD, CVVHD IHD PD 10 rnlimin 1050 to 4000 500 to 1200 450 to 540 500 to 636 15 rnYmin 1100 to 5500 600 to 1300 600 to 800 630 to 840

* Costs are presented in U.S. dollars. CVV = Continuous venovenous; CAV = Continuous arteriovenous; H = Hernofiltration; HD = Hemodialysis; IHD = Intermit-

tent hemodialysis; PD = Peritoneal dialysis.

For equivalent clearances, hemofiltration (CVVH, CAVH) can be several times more costly than hemodialysis (CVVHD, CAVHD) depending on what type of replacement solution is used. In the U.S. , the choices include some form of sterile solution usually prepared by the hospital pharmacy or com- mercially available solutions, either lactated Ring- er’s or saline with addition of potassium. Some centers in Canada have used a low glucose concentrate Dianeal as replacement solution, and other coun- tries have hemofiltration replacement solutions available from various vendors. Pharmacy prepared solutions are usually 10 times more expensive than dialysate, since the quantity is generally low, and the preparation is very labor intensive.

The cost of treatment increases for all modalities when higher amounts of therapy are delivered. While the increase in cost for intermittent therapies is more for personnel than equipment, the major cost for continuous modalities is fluid, as noted above. The equipment costs for the continuous treatments rise if there is a protocol to mandate system changes periodically, or if the system is prone to clotting. Indeed if there are frequent clotting episodes when the system efficiency is increased, the cost of continuous therapy will increase dramatically. This cost-effectiveness comparison can be a very important issue, since, in the chronic arena, higher dialysis doses seem to be more cost effective (7).

Areas of potential cost reductions in CRRT may be seen in dialyzers, personnel, dialysate and replacement fluid. Dialyzer type, performance and half-life can substantially influence cost. As note above, there does not seem to be a large difference between membrane types when used in CRRT. While there may be an advantage of polyamide with hemofiltration, and polysulfone with hemodialysis techniques, no clear-cut difference has emerged in various studies (8). Some dialyzer designs may be more beneficial for dialysate flow characteristics (9), but no clear retrospective or prospective studies to date have shown any design superiority. The cost of filters for CRRT can vary from less than $10 for a cuprophane based dialyzer to more than $100 for some of the other plastic based membranes.

Investigations into the variation in clotting rates among system and membrane types have been re- viewed elsewhere. We have found that while there is considerable patient variability, there is slightly more clotting with hemodialysis versus hemofiltration, and more clotting with the venovenous access than with the arteriovenous (it should be noted that our AV lines have been altered according to a local

design and are quite different from those routinely available from commercial sources). We have found no differences among the various membrane types when studied alone, but have found that arteriovenous hemofiltration using a polyamide membrane yielded the least clotting, while venovenous hemodialysis with a cuprophane membrane was associated with the most clotting episodes. (Table 5 )

Adequate access with sufficient blood flow can prolong dialyzer survival. It has been our experience that when the access is placed by a less expe- rienced person, the system will be prone to clotting, since the blood flow may reflect subtle changes in the access function which would translate into flow interruptions. Anticipating the patient’s placement and activity will also aid in choosing the most appropriate access site for long term entry.

In our experience, anticoagulation is rarely needed with arteriovenous techniques or for APD, while it is vital for venovenous therapy or IHD. Options for anticoagulation are expanding and are consid- ered elsewhere in this issue. The methods of anticoagulation and the lab parameters needed to monitor each vary greatly among centers. Adequate anticoagulation can maintain dialyzer efficiency and prolong dialyzer survival as well.

Finally, the determination of an adequate combi- nation of technicians, licensed practical nurses (LPNs) and registered nurses (RNs) is essential to the CRRTIIHDIAPD program and the work distribution between the ICU and nephrology staff will greatly affect cost. CRRT equipment may be in al- most continuous use and requires preventive maintenance. Proper attention to preventive maintenance can prolong machine life and lessen down- time. Once in operation, inspection of the CRRT equipment for performance and safety must be done on a regular basis by knowledgeable CRRT personnel. Off-hour and weekend coverage, availability for telephone consultation about problems or questions, implementation of order changes and similar responsibilities must be designated. It is important to emphasize the increase in personnel costs in- curred by IHD at higher dialysis doses delivered, while personnel costs with CRRT do not vary with the intensity of therapy.

Reimbursement for Continuous Renal Replacement Therapy

Physician Billing

The technical aspects of therapy include: (a) gaining access and (b) dialytic care. There are a number

212 Moreno et al.

of other services which the attending nephrologist will usually perform for patients with acute renal failure. These activities include the original consultation service, subsequent hospital visits on off- dialysis days, family meetings, and occasionally prolonged ICU retention time. These latter are well beyond the scope of this article and the reader is referred to other sources for this information (10). The current article deals with the technical aspects of continuous therapies, its physician activity and the billables generated for those activities. Contin- uous therapies will require the creation of access to the blood system for treatment delivery. When performing venovenous therapy, access is usually obtained using a double-lumen dialysis catheter which is placed percutaneously following the Seldinger technique into either the subclavian, internal jugu- lar or femoral vein. These catheters may either be placed directly, or guided through a subcutaneous tunnel. Since continuous therapy is ongoing, these lines are usually sutured in place and used for several weeks, being changed as either the patient condition or unit protocol dictates. This service is clearly reimbursable as a surgical procedure and usually billed as CPT 36489 (placement of central venous catheter), CPT 36491 (placement of CVP by cut-down), CPT 36800 (insertion of cannula for hemodialysis, other purpose. . .) (11). The ICD9 codes used most frequently in association with placement of access are 585; 586; 593.89 (uremia- acute or chronic renal failure); 276.6 (volume overload); 276.7 (hyperkalemia); and the series 960-979 (drug intoxication).

Arteriovenous access is generally obtained using the femoral artery and vein, although other sites have also been useful, especially in patients where these primary vessels are not usable. The technique is quite similar to creating an arteriovenous shunt, Scribner-type, and thus is frequently billed as CPT 36810. An alternative method has been to bill for two procedures, CPT 36245 (arterial cannulation), and CPT 3601 1 (venous cannulation). The fifty per- cent rule, (i.e. the second procedure is paid only at 50% of value) applies to this scenario (12). It would seem more appropriate to bill for the entire procedure as a shunt, and bill for catheter replacement, if needed, as separate procedures when performed. The same series of ICD9 codes usually accompa- nies the CAV- access procedures as seen with the venous cannulations.

At present, the attending physician is allowed to charge for inpatient dialytic interventions as a separate and defined entity (13). This fee for service is based upon the CPT codes which describe the procedure and physician work associated with that procedure. Dialysis support has been classified into two broad categories: intermittent therapies and continuous therapies. Each of these are further classified as either “single visit” or “multiple visit” depending upon the specific patient need. Typi- cally, the patient who undergoes CRRT will be one who is confined to the intensive care unit, has renal

TABLE 6. Variables involved in CRRT system dotting: regression model-multivariate analysis

Variable Estimate St. error T p-Value HEP vs 0-HEP -6.77 3.195 -2.12 0.034 AV vs VV 18.22 3.61 5.05 0.0001

H vs UF 5.65 5.57 1.01 0.31 Membrane 1.41 5.03 0.28 0.78 Patient* 0.16 0.026 5.92 0.0001

-2.17 0.031 HD vs H -14.07 6.47

HEP = Heparin; 0-HEP = No Heparin; AV = Arterio- venous; VV = Veno-venous; HD = Hemodialysis; H = Hemo- filtration; UF = Ultrafiltration.

* Pearson correlation at level 1 .

dysfunction, and requires fluid, electrolyte, acid/ base, or uremic control. The decision to use one form of therapy over another is left to the attending physician. There is no attempt to foster one therapy form over another based upon where the service is delivered.

Billing for a dialytic intervention on a specific day now carries the inability to bill for other physician services on that same day. This is exclusive of the original consultation, and also the procedure of gaining access. All other evaluation and management services are captured in the dialysis code reimbursement.

Intermittent codes (CFT 90935-single visit hemodialysis ; CPT 90937-multiple visit hemodialysis) are applied to intermittent hemodialysis, intermittent hemofiltration and intermittent hemodiafiltration. The description of the therapy has a distinct beginning, middle and end. Thus the use of these codes is not proposed for continuous renal support since the therapy itself is continuous and thus has no specific daily beginning or end. When the physician is required to visit the patient several time during the course of his order dialytic therapy, the higher code is allowed. This must be accompanied in the chart with adequate documentation of the required nature of the second visit, and cannot merely be the return visit of the physician for sur- veillance purposes only. There must be definitive patient need.

Continuous codes (CPT 90945-continuous peritoneal dialysis with single visit; CPT 90947- continuous dialysis techniques with multiple visits) are applied to both continuous peritoneal dialysis therapy as well as the more demanding continuous extracorporeal treatment methods (CAV-; CVVJ. Usually, the APD and CCPD therapies are billed at the lower codes and the CAVH, CVVH, CAVHD, CVVHD & SCUF therapy types demand the higher codes. The physician’s ability to be present during the therapy session (an absolute when rendering a physician charge) is eased with the continuous forms of therapy but may be more difficult with the intermittent forms since these are usually based upon staff availability and prior scheduling. All rendered bills must also be accompanied by an ICD 9 code describing the patient’s diagnosis and reasons for dialysis. While the most frequent codes remain acute renal failure (ICD9# 584.9), acute tubular ne-

COST OF CRRT 213

YEAR1992 YEAR1993 YEAR 1994

crosis (ICD9# 584.5), or hyperkalemia (ICD9# 276.7), other frequently used codes include mixed acid-base balance disorder (ICD9# 276.4) and volume overload (ICD9# 276.6). Other codes describing the patient’s overall condition and comorbid sta- tus may help in justifying higher codes, but recognize that the dialysis provider is being reimbursed only for the dialysis service and not the care of heart failure.

Frequency of billing is a variable component that seems to be quite carrier specific. With the intermittent forms of therapy, bills are usually generated when there is a procedure. If there are more than four sessions over an eight day period, the physician billing will fall outside of a carrier screen and be subject to further documentation regarding need. This can either be prepayment or postpayment, but nonetheless requires either chart documentation of need or review by panels or other physicians. The basis for the “three per week” policy stems from the chronic dialysis support patient schedules. This policy has not been established in any manner based upon the evaluation of acute dialytic data. This same screen is often applied to the continuous therapies as well. Thus rendering more than four charges over the course of eight days may require further documentation. However, there have been carriers who recognize the severity of illness that patients subjected to the continuous extracorporeal techniques generally demonstrate, and thus allow a daily charge for those procedures. There is no difference for physician billable services associated with the frequency of filter interruption, unless the physician is required to make the change person- ally. In this case, the physician may want to weigh the difference between billing ICU retention codes (CPT 99291-critical care first hour; CPT 99292- critical care, additional 30 minutes) or billing for the procedure of continuous therapies for that day (CPT 90947-continuous dialysis, multiple visit). One caution; the time billed as critical care time MUST be in necessary attendance with the patient, not in preparing the CRRT circuit, etc.

With the above description understood, the data pictured in Fig. 1 show the number of allowed charges for each of the CPT codes, and also the trend over the past three years (P. Eggers, unpub- lished data 1141). While there has been a significant increase in CPT 90935 during that time period, the other services have not shown similar growth. Rec- ognize that these are ALL inpatient dialysis profes- sional charges and are not separated by ICD 9 codes. Also these are Medicare numbers, and thus are more reflective of the Medicare population which includes all hospitalized chronic dialysis patients. Unfortunately, there are no national statistics which are readily available restricted to acute renal failure alone. Certainly the Medicare population may offer this possibility by cross-reference with the ICD9 coding system, but many of the patients with ARF in the ICU units will be outside of the Medicare payment system either by age or in-

836.5 257.2 154.3 38.8 900.4 223.7 156.9 37.8 953.4 222.9 168.4 39.3

I N - PATI E NT D I ALY S I S TEC H N I Q U E S COMPARISON 1992 THROUGH 1994

1,000 800 600 400 200

FIG. 1 . In-patient dialysis techniques, comparison 1992 through 1994

surance coverage. Fig. 2 demonstrates the relative distribution of physician services rendered to patients receiving in patient dialysis. For the usual nephrologist , these charges represent approximately 23% of entire practice billed services, and within that 23% group, continuous therapies represent only 12% of approved billings.

As more data come to light regarding the special needs of patients with acute renal dysfunction, or special needs for continuous renal replacement therapies, a more rational “screen” can be devel- oped. As the country moves more toward total capitated payment systems, the fee for service mental- ity will fade. The one major concern, however, remains the basis for this capitated rate. If the basis remains the thrice weekly dialysis screen, reimbursement may be frozen at a level that does not recognize the legitimate and needed work of the physicians, and may undermine the potential recov- ery of patients who would require more aggressive dialysis therapy. Reimbursement must also reflect physician work, more substantial with the continu-

IN-PATIENT DIALYSIS DISTHBUTION DIALYSIS SERVICE TYPE FREQUENCY - 1994

/I 90935

IC.3.. C W J 9093 7 16%

BESS DATA -Part B ExIrael & Smmury SysIem H . C . M . Olfice ofStaturics & Dolo MaMgemrnl

FIG. 2. In-patient dialysis distribution, dialysis service type frequency-1994.

214 Moreno et al.

ous extracorporeal methods than either the peritoneal or intermittent hemodialysis techniques.

Facility Reimbursement

With the implementation of the Diagnosis Related Grouping (DRG) method of hospital reimbursement (15), many of the costs for provision of services are applied to an overall capitated amount of funding for the particular hospital admission. This is closely tied to the patients’ admittinddischarge diagnosis, the case-mix index (the sum of all DRG relative weights divided by the number of Medicare cases) of the particular hospital, the presence of a training program for graduate medical education, and hospital pass-through allowables. Minimizing the use of services carried under the fixed-cost grouping will realize an increase in reimbursement as service numbers decrease. Against this background, the support of acute renal failure will increase con- sumption of resources and thus will need to be accompanied by some increase in payment. Use of services that are already present such as personnel or equipment, will allow for increased provision at minimum cost increase to the institution.

Eventually, a point is reached where any further increase in service numbers will require fixed cap- ital costs. This next service will be extremely expensive, since the incremental cost for performing that service will require acquisition of resources to accomplish the service. At this point, the hospital must decide if there is enough service increase to begin to recover the increased fixed costs, or if there is not enough potential to make this expense reasonable.

Under the present DRG system, making the most appropriate diagnosis is crucial to maximizing hospital reimbursement. This diagnosis will be given a relative weight which is assigned to specific DRGs as a measure of the resources usually consumed in association with that particular diagnosis. Remem- ber, the DRG system is an average or mean of many daerent scenarios, so that at times resource use may be less, at other times more. However the addition of acute renal failure to the diagnosis, listed as a “complication”, or the admitting diagnosis of chronic renal failure used as a comorbid condition will generally increase the arithmetic mean length of stay (AMLOS). Reimbursement computation is calculated using the geometric mean length of stay (GMLOS) which is an adjusted value of all cases with a particular DRG, making allowances for out- liers (a patient stay that exceeds the upper threshold of hospital stay for the particular DRG), transfer cases and other circumstances that might alter the basic arithmetic mean value.

As hospitals begin to negotiate for managed care contracts, all revenue-generating centers become cost centers, since every hospital admission costs the program money and reduces profits. In this ex- tension of the DRG thought process, the hospital

will usually strive to reduce or eliminate resource use which would have a negative effect on the bot- tom line. Thus, acute dialysis contracts have been looked at closely as a potential cost reduction that hospitals may achieve in helping control resource allocation. This may lead the hospital to consider the provision of acute dialytic services from its own personnel (ICU nursing, critical care physicians) and thus increase control over service costs.

Perhaps the best method of cost control is physician awareness of not only the expenses associated with the resources consumed, but also the appro- priateness of resource allocation to particular patients. While there is no clearly superior acute scor- ing system which will absolutely distinguish those patients who might benefit from those patients where no benefit will be derived, physician experience and patiedphysician relationships will help guide allocation.

Summary

Cost considerations with CRRT are important and vary substantially among centers. Major areas of concern are personnel, equipment, supplies, CRRT modality chosen and patients chosen. Costs are higher with CRRT than with either IHD or APD. These cost differences narrow as greater amounts of therapy are delivered. There are significant areas for cost control in CRRT. Each center must evaluate its program to find the areas of cost control that are potentially available.

References 1 . Reznik V, Randolph G, Collins C: Cost Analysis of Dialysis Modal-

ities for Pediatric Acute Renal Failure. Peritoneal Dialysis Interna- tional 13(4):311-313, 1993

2. Nevel M, Finke K, Renner E: Analysis and Comparison of Treatment Cost in Peritoneal Dialysis and Hemodialysis. Contributions to Ne- phrology 89:81, 1991

3. Karlberg: Cost Analysis of Alternative Treatments in End-Stage Re- nal Disease. Transplantation Proceedings 24(1):335, 1992

4. Gilbertson AA, Smith JM, Mostafa SM: The Cost of an Intensive Care Unit: A Prospective Study. Zntensive Care Med 17(4):204-208, 1991

5 . Clark W, Mueller B, Alaka K, Macias W: A Comparison of Metabolic Control by Continuous and Intermittent Therapies in Acute Renal Failure. J Am Soc Nephrol 4:1413-1420, 1994

6. S i g h MH, Teehan BP, et al.: Solute Transport in Continuous He- modialysis: A New Treatment for Acute Renal Failure. Kid Int 32: 562-571, 1987

7. Hornberger, et al.: The Hemodialysis Prescription and Cost Effec- tiveness. J Am Soc Nephrol4:1021-1027, 1993

8. Paganini EP, Lee JC, Chaff C, Sakai K: Filter l i e in continuous renal replacement therapy: access, mode, membrane and patient data. (ab- stract) J Am Soc Neph 5:423, 1994

9. Yohay D, Butterly D , Schwab S, et al.: Continuous Arteriovenous Hemodialysis: Effect of dialyser geometry. Kid Int 42:448--151, 1992

10. Trude S: Physician’s Hospital Visits: A description of rates visits under Medicare. Rand, N-3523-HCFA. 19921,

1 1 . Coy JA, et al.: CPT: Physicians’ Current Procedural Terminology. American Medical Association, Chicago, 1994

12. Federal Register Vol 56. No 108, 25792-25978. 1991 13. Federal Register Vol 59, No 235, 6341043645, 1994 14. Eggers P. Personal Communication. HCFA-Bureau of Data Man-

agement and Strategy, Office of Statistics and Data Management, 199s

15. Federal Register Vol 60, No 106, 29202-29434, 1995

Documents

Continuous Renal Replacement Therapy: Cost Considerations and Reimbursement