2026 #510 MIPS Measure First Year Standardized Waitlist Ratio (FYSWR)

‌2026 COLLECTION TYPE:

MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)

‌MEASURE TYPE:

Process

‌DESCRIPTION:

The number of newly initiated patients on dialysis in a practitioner group who are under the age of 75 and were either listed on the kidney or kidney-pancreas transplant waitlist or received a living donor transplant within the first year of initiating dialysis. The practitioner group is inclusive of physicians and advanced practice providers. The measure is the ratio-observed number of waitlist events in a practitioner group to its expected number of waitlist events. The measure uses the expected waitlist events calculated from a Cox model, which is adjusted for age, patient comorbidities, and other risk factors at the time of dialysis.

‌INSTRUCTIONS:‌

Reporting Frequency:

This measure is to be submitted a minimum of once per performance period for denominator eligible cases as defined in the denominator criteria.

‌Intent and Clinician Applicability:‌

‌This measure is intended to reflect the quality of services provided for patients within the first year of following initiation of dialysis. This measure may only be submitted by Merit-based Incentive Payment System (MIPS) eligible clinician groups who perform the quality actions as defined by the numerator based on the services provided and the measure-specific denominator coding. This measure is not intended to be reported by individual clinicians.

‌Measure Strata and Performance Rates:

This measure contains two submission criteria which together ensure capture of the full patient population and assessment of timely listing to the kidney or kidney-pancreas transplant waitlist or receipt of a living donor transplant.

There are 2 Submission Criteria for this measure:

1. Patients starting dialysis who had documentation of waitlist status at the end of the performance period.

AND

1. First Year Standardized Waitlist Ratio (FYSWR).

Submission Criteria 1 ensures a complete patient population is being assessed and measure requirements are being met. Submission Criteria 2 evaluates the expected number of waitlist events for observed events.

The measure will be calculated with 2 performance rates:

1. Percentage of patients in their first year of dialysis who had documentation of waitlist status at the end of the performance period.
2. Ratio of the observed number of waitlist events to the number of expected waitlist events.

For accountability reporting in the CMS MIPS program, the rate for Submission Criteria 2 is used for performance. For the purposes of submitting this measure, use the Data Completeness determined in Submission Criteria 1.

‌Implementation Considerations:

For the purposes of MIPS implementation, this patient-periodic measure is submitted as a ratio based upon each patient during the timeframe specified by the measure for the performance period.

Unique to this measure is the Minimum Process of Care Performance Threshold Requirement. This measure-based threshold requires that at least 90% of all eligible patients have an outcome documented by the end of the performance period. Therefore, if the performance rate for Submission Criteria 1 is below 90%, the MIPS eligible clinician would not be able to meet the denominator for Submission Criteria 2 and this measure CANNOT BE SUBMITTED. CMS anticipates the performance rate for Submission Criteria 2 will be calculated using all denominator eligible patients for Submission Criteria 1.

CMS determined that it’s not technologically feasible to calculate the 1st performance rate using the existing submission JavaScript Object Notation (JSON) structure. As a result, only the 2nd submission criteria will be accepted when submitting the measure for the performance period. While not required for submission, MIPS eligible clinicians, groups, or third-party intermediaries must continue to collect and calculate the 1st submission criteria as the data is utilized to determine if the threshold requirement for the 2nd submission criteria is met and the measure can be reported.

Technical notes describing the statistical methods used to calculate the measure, including model details, can be found on the following publicly available webpage: https://dialysisdata.org/content/MIPS. Please refer to the technical notes when calculating this measure.

‌Telehealth:

NOT TELEHEALTH ELIGIBLE: This measure is not appropriate for nor applicable to the telehealth setting. This measure is procedure based and therefore doesn’t allow for the denominator criteria to be conducted via telehealth. It would be appropriate to remove these patients from the denominator eligible patient population. Telehealth eligibility is at the measure level for inclusion within the denominator eligible patient population and based on the measure specification definitions which are independent of changes to coding and/or billing practices.

‌Measure Submission:

The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this collection type for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. The coding provided to identify the measure criteria: Denominator or Numerator, may be an example of coding that could be used to identify patients that meet the intent of this clinical topic. When implementing this measure, please refer to the ‘Reference Coding’ section to determine if other codes or code languages that meet the intent of the criteria may also be used within the medical record to identify and/or assess patients. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

SUBMISSION CRITERIA 1: PATIENTS WHO HAD DOCUMENTATION OF WAITLIST STATUS AT THE END OF THE PERFORMANCE PERIOD

‌DENOMINATOR (CRITERIA 1):‌

Patients aged less than 75 years who have initiated dialysis during January 1st – December 31st of the previous performance period.

‌DENOMINATOR NOTE:‌

‌If a dialysis practitioner group has fewer than 11 patients, then the dialysis practitioner group is excluded from reporting outcomes. The Nursing Home Minimum Dataset (MDS) and the Questions 16u and 22 on CMS Medical Evidence Form 2728 may be used to identify patients in skilled nursing facilities.

‌For the purposes of this measure, the transplant program or Organ Procurement and Transplant Network (OPTN) can be utilized as the data source for the numerator as well as patients on the kidney/kidney-pancreas waitlist prior to the initiation of dialysis.

For the purposes of determining age, utilize the date of birth given on the completed CMS Medical Evidence Form 2728 for all ESRD dialysis patients.

‌Denominator Criteria 1(Eligible Cases):

Patients aged <75 years on date of dialysis initiation during January 1st – December 31st of the previous performance period

‌AND‌

CMS Medical Evidence Form 2728 for dialysis patients: Initial form completed: M1265

AND NOT

DENOMINATOR EXCLUSIONS:

Patients admitted to a skilled nursing facility (SNF): M1266

OR 

Patients in hospice on their initiation of dialysis date or during the month of evaluation: M1263

OR

Patients that were on the kidney or kidney-pancreas waitlist prior to initiation of dialysis: M1261

OR

‌Patients who had a transplant prior to initiation of dialysis: M1262

‌NUMERATOR (CRITERIA 1):

Patients who initiated dialysis and had documentation of status at the end of the first year after initiating dialysis.

‌NUMERATOR NOTE:

Documentation of the patient’s status should indicate if denominator eligible patients were either added or not added to the kidney or kidney-pancreas transplant waitlist or if they received a living donor transplant. Patients who do not have documentation of their status at the end of the first year after initiating dialysis would be reporting as a performance not met. Documentation within the medical record doesn’t have to occur on the last day of the first year, however, for the purposes of this measure the status used to determine performance should reflect status on the last day of the first year after initiating dialysis.

‌Numerator Options:‌

Performance Met: Patient status documented within the first year of initiating dialysis (M1259)

OR

‌Performance Not Met: Patient status not documented within the first year of initiating dialysis (M1260)

AND

‌SUBMISSION CRITERIA 2: FIRST YEAR STANDARDIZED WAITLIST RATIO (FYSWR) DENOMINATOR (CRITERIA 2):‌

The denominator for the First Year Standardized Waitlist Ratio (FYSWR) is the total number of patients under the age of 75 in the practitioner group according to each patient’s treatment history for patients within the first year following initiation of dialysis.

‌DENOMINATOR NOTE:

If a dialysis practitioner group has fewer than 11 patients or 2 expected waitlist events, then the dialysis practitioner group is excluded from reporting outcomes. The Nursing Home Minimum Dataset (MDS) and the Questions 16u and 22 on CMS Medical Evidence Form 2728 may be used to identify patients in skilled nursing facilities.

For the purposes of this measure, the transplant program or Organ Procurement and Transplant Network (OPTN) can be utilized as the data source for the numerator as well as patients on the kidney/kidney-pancreas waitlist prior to the initiation of dialysis.

For the purposes of determining age, utilize the date of birth given on the completed CMS Medical Evidence Form

2728 for all ESRD dialysis patients.

Denominator Criteria 2(Eligible Cases):

Minimum Process of Care Threshold Requirement: At least 90% of all eligible patients had documentation indicating their status as of the last day for the first year after initializing dialysis (M1259 submitted for Submission Criteria 1)

AND

Patients aged <75 years on date of dialysis initiation during January 1st – December 31st of the previous performance period

AND

CMS Medical Evidence Form 2728 for dialysis patients: Initial form completed: M1265

AND NOT

DENOMINATOR EXCLUSIONS:

Patients admitted to a skilled nursing facility (SNF): M1266

OR 

Patients in hospice on their initiation of dialysis date or during the month of evaluation: M1263

OR

Patients that were on the kidney or kidney-pancreas waitlist prior to initiation of dialysis: M1261

OR

Patients who had a transplant prior to initiation of dialysis: M1262

‌NUMERATOR (CRITERIA 2):

The ratio of the observed number of waitlist events in a practitioner group to the model-based expected number of waitlist events.

‌Definitions:‌

Expected Waitlist Event – A model-based expected number of waitlist events that is calculated from a Cox model, adjusting for age, incident comorbidities, dual Medicare-Medicaid eligibility, Area Deprivation Index (from patient’s residence zip code) and transplant center characteristics. The number of days at risk (time from start of dialysis to the earliest of being placed on the waitlist, receiving a living donor transplant, death, or one year from start of dialysis) for each patient is used to calculate the expected waitlist or living donor transplant events.

Observed Waitlist Event – The number of patients placed on the kidney or kidney-pancreas waitlist or who received a living donor transplant within one year from start of dialysis.

‌NUMERATOR NOTE:

For the purposes of this measure, the transplant program or Organ Procurement and Transplant Network (OPTN) can be utilized as the data source for the numerator.

Calculations for the ratio measures are detailed below, but for more information on how to calculate FYWSR, please see Technical Notes on the Merit-based Incentive Payment System Clinical Quality Measure (MIPS CQM) for First Year Standardized Waitlist Ratio (FYSWR) found at https://dialysisdata.org/content/MIPS.

• Step One: Calculate days at risk. Days at risk is calculated as the time between the start of ESRD and date of listing on the kidney or kidney-pancreas transplant waitlist; date of receiving a living donor transplant; date of death; or 365 days after the start of ESRD dialysis treatment, whichever comes first.
• Step Two: For each patient period, calculate the linear prediction using the Model Coefficients table in the FYSWR_ModelInfo.xlsx Excel file located at https://dialysisdata.org/content/MIPS. Table 2 shows these details for the example. Note the calculations can be affected by rounding. For this calculation example, we show only four decimal places for ease of display.
• Step Three: Use the Excel file to find the baseline cumulative hazard, by finding the corresponding hazard value given the number of days at risk in the patient period. Table 3 shows these details for the example. Again, note the baseline cumulative hazard values are shown to four decimal places in this example.
• Step Four: Using the linear prediction and baseline cumulative hazard in Tables 2 and 3, compute the expected number of waitlists for each of these patients by calculating the exponentiation of the linear prediction

and multiplying by the baseline cumulative hazard.

• • The expected number of waitlists of a patient is calculated as:

Expected number of waitlists

= exp(Linear prediction)*(Baseline cumulative hazard)

• Step Five: Calculate the total expected number of waitlists by adding each patient’s expected number of waitlists for all the patients.
• Step Six: Finally, calculate FYSWR by dividing the total number of observed events (waitlists or living donor transplants) by the total number of expected waitlists.

FYWSR = Sum observed waitlist / Sum expected waitlist

RATIONALE

A measure focusing on the outcome of waitlisting is appropriate for several reasons. First, in preparing patients for suitability for waitlisting, dialysis practitioners optimize their health and functional status, improving their overall health state. Second, waitlisting is a necessary step prior to potential receipt of a deceased donor kidney transplant (receipt of a living donor kidney is also accounted for in the measure), which is known to be beneficial for survival and quality of life [1]. Third, dialysis practitioners exert substantial control over the processes that result in waitlisting. This includes proper education of dialysis patients on the option for transplant, referral of appropriate patients to a transplant center for evaluation, and assisting patients with completion of the transplant evaluation process in order to increase their candidacy for transplant waitlisting. These types of activities are included as part of the conditions for coverage for Medicare certification of ESRD dialysis facilities. Finally, wide regional and facility variations in waitlisting rates highlight substantial room for improvement for this measure [2-5].
Additionally, this measure focuses specifically on the population of patients incident to dialysis, examining for waitlist or living donor transplant events occurring within a year of dialysis initiation. This will evaluate and encourage rapid attention from dialysis practitioner groups to the optimization of health of patients to ensure early access to the waitlist, which has been demonstrated to be particularly beneficial [6-9]. This measure contrasts with the other proposed waitlisting measures, which focus on a prevalent population of dialysis patients and encourage maintenance of patients on the waitlist (Percent of Prevalent Patients Waitlisted and Percent of Prevalent Patients Waitlisted in Active Status)