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2025 MIPS Measure First Year Standardized Waitlist Ratio (FYSWR)

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2025 COLLECTION TYPE:

MIPS CLINICAL QUALITY MEASURES (CQMS)

‌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:

This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. 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 provide the measure-specific denominator coding. This measure is not intended to be reported by individual clinicians.

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 of the 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.

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. 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. 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.

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.

NOTE: Eligible Cases for this measure conducted via telehealth are not allowable.

‌Measure Submission Type:

Measure data may be submitted by MIPS eligible groups or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible groups or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:

  1. Percentage of patients in their first year of dialysis who had documentation of waitlist status at the end of the performance period

    AND

  2. Ratio of the observed number of waitlist events to the number of expected waitlist events

‌Denominator (Submission Criteria 1):

Patients aged 75 years of age or less 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 (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 (Submission 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)

‌Denominator (Submission 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 (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 (Submission 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

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