2024 MIPS Measure #482: Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate

2024 COLLECTION TYPE:

MIPS Clinical Quality Measures (CQMS)

‌MEASURE TYPE: ‌Intermediate outcome – High Priority

Description

Percentage of adult hemodialysis (HD) patient-months using a catheter continuously for three months or longer for vascular access attributable to an individual practitioner or group practice.

Instructions

This measure is to be submitted a minimum of once per month for patients who used a catheter for three patient months or longer for vascular access as defined in End Stage Renal Disease (ESRD) Quality Reporting System (EQRS) (formerly known as CROWNWeb). This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

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

Measure Submission Type

Measure data may be submitted by individual MIPS eligible clinicians, 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 clinicians, 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

All patients at least 18 years old as of the first day of the reporting month who are determined to be maintenance hemodialysis patients (in-center and home HD) for the complete reporting month under the care of the same practitioner or group partner

Definition:

Patient-months—The number of “patient-months” over a time period is the sum of patients reported for the months covered by the time period. An individual patient may contribute up to 12 “patient-months” per year.

DENOMINATOR NOTE: Only clinicians who have been caring for adult hemodialysis patients for three months or longer should report this measure. Eligible patient months are attributed to one or more clinicians of a specialty that is eligible for MIPS. Only clinicians of a specialty that is eligible for MIPS or clinician groups where the triggering clinician is of a specialty that is eligible for MIPS are attributed episodes. This measure does not exclude patients who have exhausted their vascular access options.

Denominator Criteria (Eligible Cases):

All patients aged ≥18 years as of the first day of the reporting month

AND

With maintenance hemodialysis (in-center and home HD) for the complete reporting month: G0049

AND NOT

Denominator Exclusions:

Patients with a catheter that have limited life expectancy: G0050

Patients with metastatic cancer in the 12 months prior to the numerator event reporting month

• Codes to identify metastatic cancer: C77.0, C77.1, C77.2, C77.4, C77.5, C77.8, C78.00, C78.01, C78.02, C78.1, C78.2, C78.30, C78.39, C78.4, C78.5, C78.6, C78.7, C78.80, C78.89, C79.00, C79.01, C79.02, C79.10, C79.11, C79.19, C79.31, C79.32, C79.40, C79.49, C79.51, C79.52, C79.60, C79.61, C79.62, C79.70, C79.71, C79.72, C79.89, C79.9, C7B.00, C7B.01, C7B.02, C7B.03, C7B.04, C7B.09, C7B.1, C7B.8, C80.0, C91.00, C91.01, C91.02, C92.00, C92.01, C92.02, C92.40, C92.41, C92.42, C92.50, C92.51, C92.52, C92.60, C92.61, C92.62, C92.A0, C92.A1, C92.A2, C93.00, C93.01, C93.02, C94.00, C94.01, C94.02, C95.00, C95.01, C95.02

Patients with end stage liver disease in the 12 months prior to the numerator event reporting month

• Codes to identify end stage liver disease: I85.00, I85.01, I85.10, I85.11, K70.41, K71.11, K72.01, K72.10, K72.11, K72.90, K72.91, K74.02, K76.6, K76.7, K76.81, K76.82

Patients with coma or anoxic brain injury in the 12 months prior to the numerator event reporting month

• Codes to identify coma or anoxic brain injury: E03.5, G93.1, G93.5, G93.6, R40.20, R40.2110, R40.2111, R40.2112, R40.2113, R40.2114, R40.2120, R40.2121, R40.2122, R40.2123, R40.2124, R40.2210, R40.2211, R40.2212, R40.2213, R40.2214, R40.2220, R40.2221, R40.2222, R40.2223, R40.2224, R40.2310, R40.2311, R40.2312, R40.2313, R40.2314, R40.2320, R40.2321, R40.2322, R40.2323, R40.2324, R40.2340, R40.2341, R40.2342, R40.2343, R40.2344, R40.3, S06.1XAA, S06.1XAD, S06.1XAS, S06.1X0A, S06.1X1A, S06.1X2A, S06.1X3A, S06.1X4A, S06.1X5A, S06.1X6A, S06.1X7A, S06.1X8A, S06.1X9A, S06.4XAA, S06.4XAD, S06.4XAS, S06.5XAA, S06.5XAD, S06.5XAS, S06.6XAA, S06.6XAD, S06.6XAS

OR

Patients under hospice care in the current reporting month: G0051

OR

Patients on Peritoneal Dialysis for any portion of the reporting month: G0052

OR

Patient-months where there are more than one Medicare capitated payment (MCP) provider listed for the month: G1025

Numerator:

The number of adult patient-months in the denominator who were on maintenance hemodialysis using a catheter continuously for three months or longer as of the last hemodialysis session of the reporting month

Numerator Instructions:

Inverse Measure – A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

NUMERATOR NOTE: Vascular access type for the measure is obtained from EQRS only (representative of all ESRD dialysis patients). For a given month, patients with a catheter are defined as having one of the following access types in the table below. In addition, patients with a missing value for the access type are also considered to have a catheter. EQRS is the data source for establishing the numerator. EQRS access types recorded period is from 10/1/2023 to 12/31/2024.

Table: Catheter Access Types

*Appeared beginning in September 2020.

Numerator Options:

Performance Met: The number of adult patient-months in the denominator who were on maintenance hemodialysis using a catheter continuously for three months or longer under the care of the same practitioner or group partner as of the last hemodialysis session of the reporting month (G1026)

OR

Performance Not Met: The number of adult patient-months in the denominator who were on maintenance hemodialysis under the care of the same practitioner or group partner as of the last hemodialysis session of the reporting month using a catheter continuously for less than three months (G1027)