MIPS Qualified Clinical Data Registry

The Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group, was approved by the Centers for Medicare and Medicaid Services (CMS) as a Qualified Clinical Data Registry (QCDR) for the CMS Merit-Based Incentive Payment System (MIPS) for 2019.

Ten Non-MIPS measures were approved for inclusion in the Quality Renal Registry QCDR. Organizations can also report on any of the 271 MIPS measures through Forward Health Group’s QCDR or approved Qualified Registry.

2019 MIPS Reporting Deadline: March 31, 2020

Non-MIPS Measures*

*The Renal Physicians Association (RPA) will retain the copyright and stewardship of three non-MIPS measures (RPAQIR 13-15).

2019 Non-Mips Measures

2019 QCDR Measure IDs Measure Title (REQUIRED) Measure Description (REQUIRED) Denominator (REQUIRED) Numerator (REQUIRED) Denominator Exclusions (REQUIRED) Denominator Exceptions (REQUIRED) Numerator Exclusions (REQUIRED)
RPAQIR13 Rate of Timely Documentation Transmission to Dialysis Unit/Referring Physician Percentage of patients aged 18 years and older for whom documentation is sent to the dialysis unit or referring physician within two days of the procedure completion or consultation by an interventional nephrologist, radiologist or vascular surgeon. Patients who received a procedure or consultation. Procedures include: • Ultrasonography of kidneys • Ultrasonography of AVF/AVG • Ultrasonography of peritoneal dialysis catheter • Arteriovenous fistula/graph physical exam • Physical exam prior to scheduled procedure • Ultrasound-guided renal biopsy • Insertion/maintenance of peritoneal dialysis (PD) catheters for CKD/ESRD • Insertion/maintenance of tunneled hemodialysis catheters for ESRD • Percutaneous endovascular procedures performed to manage dysfunction of arteriovenous fistulas/grafts for CKD/ESRD • Percutaneous placement/maintenance/removal of port catheter • Percutaneous placement of central venous catheter (CVC) (non dialysis) • Insertion/maintenance of tunneled CVC (non dialysis) Patients for whom documentation was sent to the dialysis unit or referring physician within 2 days of the procedure completion or consultation. None None None
RPAQIR14 Arteriovenous Graft Thrombectomy Success Rate Percentage of clinically successful arteriovenous graft (AVG) thrombectomies for patients aged 18 years and older. Patients aged 18 years and older with attempted AVG thrombectomies AVG thrombectomies for which the procedure was clinically successful. Clinical success is defined as able to dialyze successfully once with 2 needles for once treatment with that access post procedure. None Procedure was for AVF thrombectomy None
RPAQIR15 Arteriovenous Fistulae Thrombectomy Success Rate Percentage of clinically successful arteriovenous fistulae (AVF) thrombectomies for patients aged 18 years and older on maintenance hemodialysis dialysis Patients aged 18 years and older on maintenance hemodialysis with attempted AVF thrombectomies by an interventional nephrologist, interventional radiologist, or vascular surgeon. AVF thrombectomies for which the procedure was clinically successful. Clinical success is defined as able to dialyze successfully once with 2 needles using that access post procedure. None Procedure was for AVG thrombectomy None
RCOIR1 CKD 3-5 Patients Seen at the Recommended Frequency Levels CKD 3-5 Patients Seen at Recommended Frequency Levels is the percentage of patients aged 18 years and older with a diagnosis for CKD 3-5 that have been seen by the nephrologist or nephrologist’s team member in the office setting within the lowest value of the suggested frequency range per the Kidney Disease: Improving Global Outcomes (KDIGO). All patients aged 18 years and older at the beginning of the measurement period AND Diagnosis of CKD stage 3, 4, or 5 (ICD-10-CM: N18.3, N18.4, N18.5) AND Not receiving renal replacement therapy (RRT) AND Had an office-based encounter during the measurement period (CPT codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350) Patients with a total count of office visits in the measurement period at least consistent with the lower value of the suggested range. RATE 1: CKD stage 3 patients with 2 or more visits per year Diagnosis of CKD stage 3 (ICD-10-CM: N18.3) AND Had 2 or more office-based encounters during the measurement period (CPT codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350) RATE 2: CKD stage 4 patients with 3 or more visits per year Diagnosis of CKD stage 4 (ICD-10-CM: N18.4) AND Had 3 or more office-based encounters during the measurement period (CPT codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350) RATE 3: CKD stage 5 patients with 8 or more visits per year Diagnosis of CKD stage 5 (ICD-10-CM: N18.5) AND Had 3 or more office-based encounters during the measurement period (CPT codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350) New CKD stage 3 patients (ICD-10-CM: N18.3) with a new patient office based visit (CPT codes: 99201, 99202, 99203, 99204, 99205) less than 180 days from end of measurement period. New CKD stage 4 patients (ICD-10-CM: N18.4) with a new patient office based visit (CPT codes: 99201, 99202, 99203, 99204, 99205) less than 120 days from end of measurement period. New CKD stage 5 patients (ICD-10-CM: N18.5) with a new patient office based visit (CPT codes: 99201, 99202, 99203, 99204, 99205) less than 45 days from end of measurement period. Members who are have used hospice care/services in the past 12 months [HCPCS code: G9740] [SNOMED codes: 385763009, 385765002] None None
RCOIR10 Upper Extremity Edema Improvement Upper Extremity Edema Improvement is the percentage of patients with ESRD that present with upper extremity edema and report an improvement within 48 hours after an intervention has been performed. All patients aged 18 years and older at the beginning of the measurement period AND Diagnosis of ESRD (ICD-10-CM: N18.6) AND Presented for upper extremity edema and underwent an intervention during the measurement period Patients that reported improvement in their upper extremity edema within 48 hours of an intervention. None None None
RCOIR12 Tunneled Hemodialysis Catheter Success Tunneled Hemodialysis Catheter Success is the percentage of patients with ESRD that had insertion or replacement of a central venous access device during the past 12 months who received a full dialysis treatment within 72 hours of catheter insertion or replacement. All patients aged 18 years and older at the beginning of the measurement period AND Diagnosis of ESRD (ICD-10-CM: N18.6) AND had an office-based or ambulatory surgical center encounter for insertion of a central venous access device or replacement of a central venous access device during the measurement period (CPT codes 36558, 36581) Patient received full dialysis treatment as prescribed within 72 hours of catheter placement or exchange. None None None
RCOIR3 CKD 3-5 Patients with a Urine ACR or Urine PCR Lab Test CKD 3-5 Patients with a Urine ACR or Urine PCR Lab Test is the percentage of patients aged 18 years and older with a diagnosis for CKD 3-5 and not receiving Renal Replacement Treatment that have had a urine albumin to creatinine ratio lab test (ACR) or urine protein to creatinine ratio lab test (PCR) performed within the measurement period. All patients aged 18 years and older at the beginning of the measurement period AND Diagnosis of CKD stage 3, 4, or 5 (ICD-10-CM: N18.3, N18.4, N18.5) AND Not receiving renal replacement therapy (RRT) AND Had an office-based encounter during the measurement period (CPT codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350) Patients who have had an ACR or PCR lab test performed during the measurement period. None None None
RCOIR4 CKD 4-5 Patients with Transplant Referral CKD 4-5 Patients with Transplant Referral is the percentage of patients aged 18 - 65 years with a diagnosis for CKD 4-5 who are referred to a transplant center for kidney transplant evaluation. All patients aged 18- 65 years at the beginning of the measurement period AND Diagnosis of CKD stage 4, or 5 (ICD-10-CM: N18.4, N18.5) AND Not receiving renal replacement therapy (RRT) Patients who are referred to a transplant center for kidney transplant evaluation Patients who refuse a transplant referral. Patients that are not considered good candidates for a transplant by their physician None None
RCOIR5 End Stage Renal Disease (ESRD) Initiation of Home Dialysis or Self-Care End Stage Renal Disease (ESRD) Initiation of Home Dialysis or Self-Care is the percentage of all adult ESRD patients on peritoneal dialysis (PD) or home hemodialysis. All patients aged 18 years and older at the beginning of the measurement period AND Diagnosis of ESRD (ICD-10-CM: N18.6) AND Had one or more encounters during the measurement period (CPT codes: 90957, 90958, 90959, 90960, 90961, 90962, 90969, 90970) AND Initiated dialysis therapy (First Regular Date of Dialysis) during the measurement period Number of patients whose first outpatient dialysis treatment was performed using a home modality, such as peritoneal dialysis or home hemodialysis. None None None
RCOIR7 Improved Access Site Bleeding Improved Access Site Bleeding is the percentage of patients with ESRD and a vascular access site that presented for prolonged bleeding, received an intervention, and subsequently reported a reduction in post-dialysis bleeding. All patients aged 18 years and older at the beginning of the measurement period AND Diagnosis of ESRD (ICD-10-CM: N18.6) AND Presented for prolonged vascular access site bleeding and underwent an intervention during the measurement period Number of patients that reported a reduction in bleeding from their vascular access site after an intervention at their next dialysis treatment. Patients taking current anticoagulation including warfarin, apixaban, dabigatran, rivaroxaban, ticagrelor, clopidogrel, prasugrel, and dipyridamole. None None
2019 QCDR Measure IDs Measure Title (REQUIRED) Measure Description (REQUIRED) Denominator (REQUIRED) Numerator (REQUIRED) Denominator Exclusions (REQUIRED) Denominator Exceptions (REQUIRED) Numerator Exclusions (REQUIRED)