| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Outcome | Yes | Effective Clinical Care |
Measure Description
Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated
Instruction
This measure is to be reported a minimum of once per performance period for patients with ESRD who initiated maintenance hemodialysis 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.
Denominator
All patients aged 18 years and older with a diagnosis of ESRD who initiate maintenance hemodialysis during the measurement period
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
Initiation of maintenance hemodialysis during the reporting/maintenance period
AND NOT
DENOMINATOR EXCLUSIONS:
Patient is undergoing palliative dialysis with a catheter: G9747
OR
Patient approved by a qualified transplant program and scheduled to receive a living donor kidney
transplant: G9748
Numerator
Patients whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated
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 catheter use.
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 whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated (G9240)
OR
Denominator Exception: Documentation of reasons for patient initiating maintenance hemodialysis with a catheter as the mode of vascular access (e.g., patient has a maturing AVF/AVG, time-limited trial of hemodialysis, other medical reasons, patient declined AVF/AVG, other patient reasons, patient followed by reporting nephrologist for fewer than 90 days, other system reasons) (G9239)
OR
Performance Not Met: Patient whose mode of vascular access is not a catheter at the time maintenance hemodialysis is initiated (G9241)