Technical Specifications for ESRD QIP Measures

Technical Specifications for ESRD QIP Measures

From 2010 to 2014, Arbor Research Collaborative for Health, in collaboration with the University of Michigan Kidney and Epidemiology Cost Center (UM-KECC), developed, maintained, and updated the ESRD QIP quality measures for CMS under the Quality Measure Development and Maintenance contract with CMS. These included the Clinical Performance Measures (CPM), the Dialysis Facility Compare (DFC) Measures, and the development of new quality measures.

New measures, as well as those that are revised, go through the National Quality Forum (NQF) Consensus Development Process. Once measures are in use, CMS requires that they periodically be reevaluated. This is to determine, for example, whether revisions are necessary in response to new clinical evidence or a change in clinical guidelines since the last cycle of review.

The technical specifications for prior proposed and final rules can be found in the following list.

(Note: Prior to Payment Year (PY) 2015, the publication of stand-alone technical specifications as part of the rulemaking process was limited to clinical measures; therefore, technical specifications for the reporting measures in PY 2014 are not available. Further, specifications for the PY 2012 measures were not published in a stand-alone format; that content was included in the Guide to the 2010 Dialysis Facility Reports: Overview, Methodology, and Interpretation, published by Arbor Research. Likewise, because the two measures used in PY 2013 were continuations of PY 2012 measures, no stand-alone PY 2013 technical specifications were published as part of the rulemaking process.)

Please take note that the rulemaking process refers to calendar years (CY) for the ESRD Prospective Payment System (PPS), of which ESRD QIP regulations are a part. ESRD QIP PY refers to the year in which a payment reduction would apply as a result of facility performance. In addition, an ESRD PPS CY rule often covers more than one ESRD QIP PY. For example, the CY 2022 ESRD PPS final rule established ESRD QIP PYs 2022 - 2025.  

Current Technical Specifications of Record

The following files contain the most recent finalized technical specifications for the ESRD QIP.

Calendar Year Proposed and Final Rule Specifications

The following presentations are brief summaries of each proposed and final rules. Complete proposals and finalized policies are located on the Federal Register.

CY 2024 ESRD PPS Proposed Rule

CY 2023 ESRD PPS Final Rule

  • Suppression of seven measures under the measure suppression policy for the PY 2024
  • Express the Standardized Hospitalization Ratio (SHR) and Standardized Readmission Ratio (SRR) clinical measures results as rates beginning with PY 2024
  • Adopt COVID-19 Vaccination Coverage among Healthcare Personnel to the ESRD QIP measure set beginning with PY 2025.
  • Convert the Standardized Transfusion Ratio (STrR) reporting measure to a clinical measure and express as a rate beginning with PY 2025
  • Convert the Hypercalcemia clinical measure to a reporting measure and update the scoring methodology beginning with PY 2025
  • Use CY 2019 data to calculate performance standards and update mTPS
    • Update the mTPS for PY 2023 to include non-paused measures
    • Re-calculate the mTPS to 83 to address addition of the Standardized Fistula Rate clinical measure  
  • Create a new Reporting Measure domain and re-weight current domains beginning with PY 2025

CY 2023 ESRD PPS Proposed Rule

  • Suppression of six measures under the measure suppression policy for PY 2023 program year
  • Express the Standardized Hospitalization Ratio (SHR) and Standardized Readmission Ratio (SRR) clinical measures results as rates
  • Add COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) measure to the ESRD QIP measure set
  • Convert the Standardized Transfusion Ratio (STrR) reporting measure to a clinical measure and express as a rate
  • Convert the Hypercalcemia clinical measure to a reporting measure
  • Use CY 2019 data to calculate performance standards and update mTPS
  • Create a new Reporting Measure domain and re-weight current domains
  • CY 2023 Proposed Technical Measure Specifications (PDF)

CY 2022 ESRD PPS Final Rule

The CY 2022 ESRD PPS final rule was posted by CMS on November 8, 2021. It finalized:

  • Measure suppression policy for the duration of the COVID-19 PHE
  • Adopt four measure suppression factors to help determine whether to suppress measures that overlap the PHE
  • Update the Scoring Policy/Performance standards
  • Update the Standardized Hospitalization Ratio (SHR) Measure
  • CY 2022 Technical Measure Specifications (PDF)

CY 2022 ESRD PPS Proposed Rule

The CY 2022 ESRD PPS final rule was posted by CMS on July 1, 2021. It proposed:

  • Measure suppression policy for the duration of the COVID-19 PHE
  • Adopt four measure suppression factors to help determine whether to suppress measures that overlap the PHE
  • Update the Scoring Policy/Performance standards
  • Update the Standardized Hospitalization Ratio (SHR) Measure
  • CY 2022 Proposed Technical Measure Specifications (PDF)

CY 2021 ESRD PPS Final Rule

The CY 2021 ESRD PPS final rule was posted by CMS on November 9, 2020. It finalized:

  • Revising the scoring methodology for the Ultrafiltration Rate (UFR) Reporting Measure
  • Clarifications of the timeline to make changes to National Healthcare Safety Network (NHSN) Blood stream Infection (BSI) and NHSN Dialysis Event Reporting
  • Decreasing the number of records required for the NHSN Validation CY 2021 Final technical specifications for the PY 2023 ESRD QIP (PDF) (PDF)

CY 2021 ESRD PPS Proposed Rule

The CY 2021 ESRD PPS proposed rule was posted by CMS on July 6, 2020. It proposed:

CY 2020 ESRD PPS Final Rule

The CY 2020 ESRD PPS final rule was posted by CMS on November 8, 2019. It finalized:

  • Updating scoring methodology for the NHSN Dialysis Event reporting measure
  • Converting STrR clinical measure (NQF #2979) into a reporting measure
  • Codifying program requirements in regulation text
  • Continuing of the NHSN validation study in PY 2023 and beyond

CY 2020 ESRD PPS Proposed Rule

The CY 2020 ESRD PPS proposed rule was posted by CMS on July 29, 2019.  It proposed:

  • Updating scoring methodology for the NHSN Dialysis Event reporting measure
  • Converting STrR clinical measure (NQF #2979) into a reporting measure
  • Revising MedRec reporting measure's scoring equation
  • Codifying program requirements in regulation text
  • Continuing of the NHSN validation study in PY 2023 and beyond

Proposed Technical Specifications for the PY 2022 ESRD QIP (PDF)

Proposed Technical Specifications for the PY 2023 ESRD QIP (PDF)

CY 2019 ESRD PPS Final Rule

The CY 2019 ESRD PPS final rule was posted by CMS on November 14, 2018. It finalized:

  • Modifications to the PY 2021 ESRD QIP;
  • Clinical and reporting measures for the PY 2022 and beyond;
  • Programmatic changes and alignment with Meaningful Measures.

CY 2019 ESRD PPS Proposed Rule 

The CY 2019 ESRD PPS proposed rule was posted by CMS on July 11, 2018. It proposed:

  • Modifications to the PY 2021 ESRD QIP;
  • Clinical and reporting measures for the PY 2022 ESRD QIP;
  • A clinical measure for the PY 2024 ESRD QIP; and
  • Programmatic changes.

The CY 2019 ESRD PPS proposed rule for PY 2022 included clinical measures for Percentage of Prevalent Patients Waitlisted (PPPW) and Patients Receiving Care at Dialysis Facilities (MedRec). It also included a clinical measure for PY 2024 for Standardized First Kidney Transplant Waitlist Ratio for Incident Dialysis Facilities (SWR).

Proposed technical specifications for the PY 2021 ESRD QIP (PDF) (PDF)

Proposed technical specifications for the PY 2022 ESRD QIP (PDF) (PDF)

Proposed technical specifications for the PY 2024 ESRD QIP (PDF) (PDF)

Analyses Supporting the CY 2019 ESRD PPS Proposed Rule 

The CY 2019 ESRD PPS proposed rule referenced the following analyses supporting the ESRD QIP proposals made by CMS.

CY 2018 ESRD PPS Final Rule

The CY 2018 ESRD PPS proposed rule was posted by CMS on November 1, 2017. It finalized:

  • Clinical and reporting measures for the PY 2021 ESRD QIP;
  • Modifications to PY 2019 and PY 2020 ESRD QIP; and
  • Programmatic changes.

Analyses Supporting the CY 2018 ESRD PPS Final Rule

The CY 2018 ESRD PPS final rule referenced the following analyses supporting the ESRD QIP policies made by CMS.

CY 2018 ESRD PPS Proposed Rule

The CY 2018 ESRD PPS proposed rule was posted by CMS on June 29, 2017. It proposed:

  • Clinical and reporting measures for the PY 2021 ESRD QIP;
  • Modifications to PY 2019 and PY 2020 ESRD QIP; and
  • Programmatic changes.
Proposed Measure Specifications for the PY 2021 ESRD QIP (PDF)

The CY 2018 ESRD PPS proposed rule for PY 2021 included revised clinical measures for Vascular Access Type measure topic and Standardized Transfusion Ratio.

Analyses Supporting the CY 2018 ESRD PPS Proposed Rule

The CY 2018 ESRD PPS proposed rule referenced the following analyses supporting the ESRD QIP proposals made by CMS.

 

CY 2017 ESRD PPS Final Rule 

The CY 2017 ESRD PPS final rule was posted by CMS on October 28, 2016.

Final Measure Specifications for the PY 2020 ESRD QIP (PDF)

This final rule containing measures for Payment Year 2020 was posted by CMS on October 28, 2016.

Final Measure Specifications for the PY 2019 ESRD QIP (PDF)

This final rule containing revised measures for Payment Year 2019 was posted by CMS on October 28, 2016.

Final Measure Specifications for the PY 2018 ESRD QIP (PDF)

This final rule containing revised measures for Payment Year 2018 was posted by CMS on October 28, 2016.

Analysis Supporting the CY 2017 ESRD PPS Final Rule

The CY 2017 ESRD PPS final rule referenced the following analysis supporting the ESRD QIP policies made by CMS.

 

CY 2017 ESRD PPS Proposed Rule

The CY 2017 ESRD PPS proposed rule was posted by CMS on June 24, 2016. It proposed:

  • Clinical and reporting measures for the PY 2020 ESRD QIP;
  • Modifications to PY 2019 and PY 2018 ESRD QIP; and
  • Programmatic changes.

Proposed Measure Specifications for the PY 2020 ESRD QIP (PDF) 

The CY 2017 ESRD PPS proposed rule for PY 2020 included adding a Standardized Hospitalization Ratio (SHR) clinical measure and an Ultrafiltration Rate reporting measure, as well as replacing the prior Mineral Metabolism reporting measure with a Serum Phosphorus reporting measure.

Proposed Measure Specification for the PY 2019 ESRD QIP (PDF) 

The CY 2017 ESRD PPS proposed rule included reintroducing the NHSN Dialysis Event reporting measure.

Proposed Measure Specification for the PY 2018 ESRD QIP (PDF)

The CY 2017 ESRD PPS proposed rule included revising the previously finalized Hypercalcemia clinical measure.

Analyses Supporting the CY 2017 ESRD PPS Proposed Rule

The CY 2017 ESRD PPS proposed rule referenced the following analyses supporting the ESRD QIP proposals made by CMS.

 

CY 2016 ESRD PPS Final Rule

The CY 2016 ESRD PPS final rule was posted by CMS on October 30, 2015.

Final Measure Specifications for the PY 2019 ESRD QIP (PDF)

This final rule containing measures for Payment Year 2019 was posted by CMS on October 30, 2015.

Final Measure Specifications for the PY 2018 ESRD QIP (PDF)

This final rule containing measures for Payment Year 2018 was posted by CMS on October 30, 2015.

Final Measure Specifications for the PY 2017 ESRD QIP (PDF)

This final rule containing proposed measures for Payment Year 2017 was posted by CMS on October 30, 2015.

 

CY 2016 ESRD PPS Proposed Rule

The CY 2016 ESRD PPS proposed rule was posted by CMS on June 26, 2015. It proposed:

  • Clinical and reporting measures for the PY 2019 ESRD QIP;
  • Modifications to PY 2018 and PY 2017 ESRD QIP; and
  • Programmatic changes.

Proposed Measure Specifications for the PY 2019 ESRD QIP (PDF) 

The CY 2016 ESRD PPS proposed rule included a comprehensive Kt/V Dialysis Adequacy rule that consolidates the four individual measures finalized in earlier Payment Years.

Analyses Supporting the CY 2016 ESRD PPS Proposed Rule

The CY 2016 ESRD QIP proposed rule referenced the following analyses supporting the proposals made by CMS.

Proposed Measure Specifications for the PY 2018 ESRD QIP (PDF)

The CY 2016 ESRD PPS proposed rule included minor text edits to the measure specifications for Payment Year 2018 ESRD QIP to improve documentation consistency; it also proposed a scoring modification for the Pain Assessment and Follow-Up reporting measure.

Proposed Measure Specifications for the PY 2017 ESRD QIP (PDF)

The CY 2016 ESRD PPS proposed rule included minor text edits to the measure specifications for Payment Year 2017 ESRD QIP to improve documentation consistency; it also proposes to reinstate the CROWNWeb-based attestations regarding qualifying patients for the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems reporting measure.

 

CY 2015 ESRD PPS Final Rule

The CY 2015 ESRD PPS final rule was posted by CMS on October 31, 2014.

Final Measure Specifications for the PY 2018 ESRD QIP (PDF)

This final rule containing measures for Payment Year 2018 was posted by CMS on October 31, 2014.

Final Measure Specifications for the PY 2017 ESRD QIP (PDF)

This final rule containing proposed measures for Payment Year 2017 was posted by CMS on October 31, 2014.

 

CY 2015 ESRD PPS Proposed Rule

The CY 2015 ESRD PPS proposed rule was posted by CMS on July 2, 2014. It proposed:

  • Clinical and reporting measures for the PY 2018 and PY 2017 ESRD QIP
  • Modifications to the NHSN Bloodstream Infection clinical measure for PY 2016; and
  • Programmatic changes. 

Proposed Measure Specifications for the PY 2018 ESRD QIP (PDF)

This proposed rule containing proposed measures for Payment Year 2018 was posted by CMS on July 2, 2014.

Proposed Measure Specifications for the PY 2017 ESRD QIP (PDF)

This proposed rule containing proposed measures for Payment Year 2017 was posted by CMS on July 2, 2014.

 Proposed Measure Modification for the PY 2016 ESRD QIP (PDF)

The PY 2017 – PY 2018 proposed rule posted by CMS on July 2, 2014, included a proposed modification for the NHSN Bloodstream Infections in Hemodialysis Outpatients clinical measure for Payment Year 2016.

Analyses Supporting CY 2015 ESRD PPS Proposed Rule

The PY 2017 – PY 2018 ESRD QIP proposed rule posted by CMS on July 2, 2014, referenced the following analyses supporting the proposals made by CMS.

 

CY 2014 ESRD PPS Final Rule

The CY 2014 ESRD PPS final rule was displayed by CMS on November 22, 2013.

Final Measure Specifications for the PY 2016 ESRD QIP (PDF)

This final rule containing measures for Payment Year 2016 was displayed by CMS on November 22, 2013.

 

CY 2014 ESRD PPS Proposed Rule

The CY 2014 ESRD PPS proposed rule was posted by CMS on July 1, 2013. It proposed clinical and reporting measures for the PY 2016 ESRD QIP.

Proposed Measure Specifications for the PY 2016 ESRD QIP (PDF)

This proposed rule containing proposed measures for Payment Year 2016 was posted by CMS on July 1, 2013.

 

CY 2013 ESRD PPS Final Rule

The CY 2013 ESRD PPS final rule was published by CMS on November 2, 2012.

Final Measure Specifications for the PY 2015 ESRD QIP (PDF)

This final rule containing measures for Payment Year 2015 was published by CMS on November 2, 2012.

 

CY 2013 ESRD PPS Proposed Rule

The CY 2013 ESRD PPS proposed rule was posted by CMS on July 2, 2012. It proposed clinical and reporting measures for the PY 2015 ESRD QIP.

Proposed Measure Specifications for the PY 2015 ESRD QIP (PDF)

This proposed rule containing proposed measures for Payment Year 2015 was posted by CMS on July 2, 2012.

 

CY 2012 ESRD PPS Final Rule

The CY 2012 ESRD PPS final rule was published by CMS on November 1, 2011.

PY 2014 ESRD QIP Performance Standards (PDF)

Performance standards for Payment Year 2014 are calculated using data collected over a full year (July 1, 2010 through June 30, 2011) in accordance with the Final Rule published by CMS on November 1, 2011.

Final Clinical Measure Specifications for the PY 2014 ESRD QIP (PDF)

This final rule containing measures for Payment Year 2014 was published by CMS on November 1, 2011.

Final Measure Specifications for the PY 2013 ESRD QIP (PDF)

This final rule containing measures for Payment Year 2013 was published by CMS on November 1, 2011.

 

CY 2012 ESRD PPS Proposed Rule

The CY 2012 ESRD PPS proposed rule was posted by CMS on July 1, 2011. It proposed clinical and reporting measures for the PY 2014 ESRD QIP, as well as measures for the PY 2013 ESRD QIP.

Proposed Clinical Measure Specifications for the PY 2014 ESRD QIP (PDF)

This proposed rule containing measures for Payment Year 2014 was published by CMS on July 1, 2011.

Page Last Modified:
09/06/2023 04:57 PM
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