| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Outcome | Yes | Patient Safety |
Measure Description
Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter
Instruction
This measure is to be reported a minimum of once per performance period for patients with ESRD seen during the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
NOTE: Include only patients that have catheters at the time of initiation of hemodialysis through September 30 of the performance period. This will allow the evaluation of at least 90 days of catheter use for hemodialysis within the reporting year.
Denominator
All patients aged 18 years and older with a diagnosis of ESRD receiving maintenance hemodialysis for greater than or equal to 90 days
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for ESRD (ICD-10-CM): N18.6, Z49.31
AND
Patient encounter during performance period (CPT): 90957, 90958, 90959, 90960, 90961, 90962, 90966, 90970
WITHOUT
Telehealth Modifier: GQ, GT
AND
All eligible instances of quality-data code G9240 (Documentation of patient with a catheter at the time maintenance hemodialysis is initiated as applied in the numerator for Measure #329 Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis)
AND NOT
DENOMINATOR EXCLUSIONS:
Patient is undergoing palliative dialysis with a catheter: G9749
OR
Patient approved by a qualified transplant program and scheduled to receive a living donor kidney transplant: G9750
Numerator
Patients whose mode of vascular access is a catheter
Numerator Instructions: Of note, the performance tags indicating “Performance Met? and “Performance Not Met? are included to highlight what is being measured and reported and not to encourage extended use of catheters for vascular access.
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. Reporting 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 Options:
Performance Met: Patient receiving maintenance hemodialysis for greater than or equal to 90 days with a catheter as the mode of vascular access (G9265)
OR
Denominator Exception: Documentation of patient receiving maintenance hemodialysis for greater than or equal to 90 days with a catheter for documented reasons (e.g. other medical reasons, patient declined AVF/AVG, other patient reasons) (G9264)
OR
Performance Not Met: Patient receiving maintenance hemodialysis for greater than or equal to 90 days without a catheter as the mode of vascular access (G9266)