CMS SOM App. H, Tag V546

address, but not be limited to, the following: (3) Mineral metabolism. Provide the necessary

care to manage mineral metabolism and prevent or treat renal bone disease.

Interpretive Guidance § 494.90(a)(3)

Disturbances in mineral and bone metabolism are common in patients with ESRD, often

resulting in hyperparathyroidism and Chronic Kidney Disease (CKD) mineral and bone

disorder, if not managed effectively. The lab markers of calcium, phosphorus, and parathyroid

hormone (PTH) are generally used to monitor mineral metabolism.

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Expect the facility to have established target goals for patients’ calcium, phosphorus, and PTH

levels, which reflect professionally accepted clinical practice standards. Refer to the Measures

Assessment Tool (MAT), which lists the targets for CKD mineral and bone disorder.

Interventions for prevention and management of CKD mineral and bone disorder may include

nutritional counseling and the administration of medications (e.g., phosphate binders, vitamin D

analogs, calcimimetic agents). If the facility is using a medication algorithm/protocol for

managing CKD mineral and bone disorder, the care for each patient must be individualized. The

physician or non-physician practitioner (i.e., advanced practice registered nurse or physician

assistant) is responsible for ordering medications and laboratory tests and may or may not

prescribe standing orders or utilize a standard algorithm.

Pediatric patients have special growth and development needs that require management in this

area. Facilities treating pediatric patients should have specialized methods for monitoring and

management of CKD mineral and bone disorder.

The methods used for managing CKD mineral and bone disorder should be evident in the review

of records, including laboratory reports, orders for CKD mineral and bone disorder

management medications (e.g., vitamin D analogs), and medication administration records.

Each patient’s laboratory values must be monitored, values outside the target levels addressed,

doses adjusted, and medications administered as ordered. If the patient’s mineral metabolism

goals are not being attained to “manage and prevent or treat” CKD mineral and bone disorder,

the team should identify potential causes and address the barriers that may be preventing the

patient from reaching the target values (e.g., failure to take medications or follow prescribed

diet, lack of understanding or resources to obtain medications). Patients should be educated to

understand their role in managing the prescribed diet, medications, and managing bone health.

Enlistment of patients to be involved in their care is critical to success and attainment of these

goals.

The requirements for patient assessment of CKD mineral and bone disorder are at V508.