MIPS CLINICAL QUALITY MEASURES (CQMS)
Description:
The measure tracks dialysis patients who are under the age of 75 in a practitioner group and on the kidney or kidney- pancreas transplant waitlist (all patients or patients in active status). This measure is a risk-adjusted percentage of waitlist events among dialysis patients.
Instructions:
This measure data is to be submitted a minimum of once per month for patients seen during the performance period. This measure is intended to reflect the quality of services provided for patients on dialysis with a diagnosis for End- Stage Renal Disease. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible groups who provide the measure-specific denominator coding. This measure is not intended to be reported by individual clinicians.
This measure will be calculated with 2 performance rates:
- Percentage of Prevalent Patients Waitlisted (PPPW)
- Percentage of Prevalent Patients Waitlisted in Active Status (aPPPW)
For accountability reporting in the CMS MIPS program, the rate for Submission Criteria 2 is used for performance.
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.
Denominator (Submission Criteria 1):
All risk-adjusted patient-months for patients who are under the age of 75 in the reporting month and who are assigned to a dialysis practitioner or practitioner group practice according to each patient’s treatment history on the last day of each reporting month during the performance year.
Definitions:
End-Stage Renal Disease (ESRD) Monthly Capitated Payment (MCP) – An ESRD MCP is a monthly payment made to physicians for dialysis-related physician services provided to Medicare ESRD patients. Risk-Adjusted Months on the Waitlist – The risk-adjusted number of patient-months on the waitlist is calculated from a mixed-effects logistic regression model, adjusting for age, patient comorbidities, other risk factors at incidence of dialysis, random effects for transplant centers and assuming the practitioner group-
specific event rate equals the population average.
Reporting Month – The last day of each calendar month.
DENOMINATOR NOTE: All patients who meet the denominator inclusion criteria are included and used to model a given dialysis practitioner group’s risk-adjusted waitlist rate. The Nursing Home Minimum Dataset (MDS) and 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 more information on how to calculate the risk-adjusted months on the waitlist and observed months on the waitlist please see please see the technical notes found at https://dialysisdata.org/content/MIPS.
If a dialysis practitioner group has fewer than 11 patients during the performance year, the dialysis practitioner group is excluded from reporting outcomes.
Denominator Criteria (Eligible Cases):
All patients aged <75 years old on the last day of the reporting month
AND
Receiving ESRD MCP dialysis services by the provider on the last day of the reporting month: M1269
AND NOT
DENOMINATOR EXCLUSIONS:
Patients who were admitted to a skilled nursing facility (SNF) during the month of evaluation were excluded from that month: M1274
OR
Patients who were admitted to a skilled nursing facility (SNF) within one year of dialysis initiation according to the CMS-2728 form: M1273
OR
Patients determined to be in hospice were excluded from month of evaluation and the remainder of reporting period: M1275
OR
Patients with dementia at any time prior to or during the month: M1271
Numerator (Submission Criteria 1):
Percentage of Prevalent Patients Waitlisted (PPPW): Patients in the practitioner group’s denominator with observed months on the waitlist for each month
Definition:
Observed Months on the Waitlist – The number of patient-months on the waitlist in a practitioner group.
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.
Numerator Options:
Performance Met: Patients observed on any kidney or kidney-pancreas transplant waitlist as of the last day of each month during the measurement period (M1272)
OR
Performance Not Met: Patients not on any kidney or kidney-pancreas transplant waitlist as of the last day of each month during the measurement period (M1270)
Denominator (Submission Criteria 2):
All risk-adjusted patient-months for patients who are under the age of 75 in the reporting month and who are assigned to a dialysis practitioner or practitioner group practice according to each patient’s treatment history on the last day of each reporting month during the performance year.
Definitions:
End-Stage Renal Disease (ESRD) Monthly Capitated Payment (MCP) – An ESRD MCP is a monthly payment made to physicians for dialysis-related physician services provided to Medicare ESRD patients.
Risk-Adjusted Months on the Waitlist in Active Status – The risk-adjusted number of patient-months on the waitlist in active status is calculated from a mixed-effects logistic regression model, adjusting for age, patient comorbidities, other risk factors at incidence of dialysis, random effects for transplant centers and assuming the practitioner group-specific event rate equals the population average.
Reporting Month – The last day of each calendar month.
DENOMINATOR NOTE: All patients who meet the denominator inclusion criteria are included and used to model a given dialysis practitioner group’s risk-adjusted waitlist rate. The Nursing Home Minimum Dataset (MDS) and 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 more information on how to calculate the risk-adjusted months on the waitlist in active status and observed months on the waitlist in active status please see please see the technical notes found at https://dialysisdata.org/content/MIPS.
If a dialysis practitioner group has fewer than 11 patients during the performance year, the dialysis practitioner group is excluded from reporting outcomes.
Denominator Criteria (Eligible Cases):
All patients aged <75 years old on the last day of the reporting month
AND
Receiving ESRD MCP dialysis services by the provider on the last day of the reporting month: M1269
AND NOT
DENOMINATOR EXCLUSIONS:
Patients who were admitted to a skilled nursing facility (SNF) during the month of evaluation were excluded from that month: M1274
OR
Patients who were admitted to a skilled nursing facility (SNF) within one year of dialysis initiation according to the CMS-2728 form: M1273
OR
Patients determined to be in hospice were excluded from month of evaluation and the remainder of reporting period: M1275
OR
Patients with dementia at any time prior to or during the month: M1271
Numerator (Submission Criteria 2):
Percentage of Prevalent Patients Waitlisted in Active Status (aPPPW): Patients in the practitioner group’s denominator with observed months on the waitlist in active status for each month
Definition:
Observed Months on the Waitlist in Active Status – Observed number of patient-months on the wait list in active status in a practitioner group.
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.
For more information on how to calculate the risk-adjusted months on the waitlist in active status and observed months on the waitlist in active status please see please see the technical notes found at https://dialysisdata.org/content/MIPS.
Performance Met: Patients observed in active status on any kidney or kidney-pancreas transplant waitlist as of the last day of each month during the measurement period (M1268)
OR
Performance Not Met: Patients not observed in active status on any kidney or kidney-pancreas transplant waitlist as of the last day of each month during the measurement period (M1267)
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