Centers for Medicare & Medicaid Services Center for Clinical Standards and Quality CMS ESRD Measures Manual for the 2021 Performance Period Final Version 6.1 November 30, 2020 Final Centers for Medicare & Medicaid Services Table of Contents 1. Introduction .................................................................................................................. 1 2. Measurement Information .......................................................................................... 2 2.1 Vascular Access Type Clinical Measure: Hemodialysis Vascular Access: Long-term Catheter Rate (ESRD QIP and DFC) ................................................................................2 2.1.1 Measure Name .....................................................................................................2 2.1.2 Measure Description ............................................................................................2 2.1.3 Measure Rationale ...............................................................................................2 2.1.4 Measure Type ......................................................................................................2 2.1.5 Improvement Noted as Higher or Lower Rate ....................................................2 2.1.6 Numerator Statement ...........................................................................................2 2.1.7 Facility Exclusions ..............................................................................................3 2.1.8 Denominator Statement .......................................................................................3 2.1.9 Denominator Exclusions .....................................................................................3 2.1.10 Denominator Details ............................................................................................3 2.1.11 Mapping Patients to Facilities .............................................................................4 2.1.12 Calculating Numerators .......................................................................................4 2.1.13 Data Elements and Data Source ..........................................................................5 2.1.14 Flowchart .............................................................................................................6 2.1.15 Selected References .............................................................................................8 2.2 Hemodialysis Vascular Access: Standardized Fistula Rate (ESRD QIP and DFC) .........9 2.2.1 Measure Name .....................................................................................................9 2.2.2 Measure Description ............................................................................................9 2.2.3 Measure Rationale ...............................................................................................9 2.2.4 Measure Type ......................................................................................................9 2.2.5 Improvement Noted as Higher or Lower Rate ....................................................9 2.2.6 Risk Adjustment ................................................................................................10 2.2.7 Numerator Statement .........................................................................................10 2.2.8 Facility Exclusions ............................................................................................10 2.2.9 Denominator Statement .....................................................................................10 2.2.10 Denominator Exclusions ...................................................................................10 2.2.11 Denominator Details ..........................................................................................10 2.2.12 Mapping Patients to Facilities ...........................................................................11 2.2.13 Calculating Numerators .....................................................................................11 2.2.14 Statistical Risk Model and Variables ................................................................12 2.2.15 Data Elements and Data Sources .......................................................................13 2.2.16 Flowchart ...........................................................................................................16 2.2.17 Selected References ...........................................................................................17 2.3 Adult Hemodialysis Adequacy Measure (DFC Only) ....................................................18 2.3.1 Measure Name ...................................................................................................18 2.3.2 Measure Description ..........................................................................................18 2.3.3 Measure Rationale .............................................................................................18 2.3.4 Measure Type ....................................................................................................18 CMS ESRD Measures Manual for the 2021 Performance Period i Version 6.1 November 30, 2020 Final Centers for Medicare & Medicaid Services 2.3.5 Improvement Noted as Higher or Lower Rate ..................................................18 2.3.6 Risk Adjustment ................................................................................................18 2.3.7 Numerator Statement .........................................................................................18 2.3.8 Facility Exclusions ............................................................................................18 2.3.9 Denominator Statement .....................................................................................19 2.3.10 Denominator Exclusions ...................................................................................19 2.3.11 Mapping Patients to Facilities ...........................................................................19 2.3.12 Calculating Numerators .....................................................................................19 2.3.13 Assigning Patient-Months to Numerators and Denominators ...........................20 2.3.14 Data Elements and Data Sources .......................................................................20 2.3.15 Selected References ...........................................................................................21 2.4 Adult Peritoneal Dialysis Adequacy Measure (DFC Only) ............................................22 2.4.1 Measure Name ...................................................................................................22 2.4.2 Measure Description ..........................................................................................22 2.4.3 Measure Rationale .............................................................................................22 2.4.4 Measure Type ....................................................................................................22 2.4.5 Improvement Noted as Higher or Lower Rate ..................................................22 2.4.6 Risk Adjustment ................................................................................................22 2.4.7 Numerator Statement .........................................................................................22 2.4.8 Facility Exclusions ............................................................................................22 2.4.9 Denominator Statement .....................................................................................22 2.4.10 Denominator Exclusions ...................................................................................23 2.4.11 Mapping Patients to Facilities ...........................................................................23 2.4.12 Calculating Numerators .....................................................................................23 2.4.13 Assigning Patient-Months to Numerators and Denominators ...........................23 2.4.14 Data Elements and Data Sources .......................................................................23 2.4.15 Selected References ...........................................................................................24 2.5 Pediatric Hemodialysis Adequacy Measure (DFC Only) ...............................................25 2.5.1 Measure Name ...................................................................................................25 2.5.2 Measure Description ..........................................................................................25 2.5.3 Measure Rationale .............................................................................................25 2.5.4 Measure Type ....................................................................................................25 2.5.5 Improvement Noted as Higher or Lower Rate ..................................................25 2.5.6 Risk Adjustment ................................................................................................25 2.5.7 Numerator Statement .........................................................................................25 2.5.8 Facility Exclusions ............................................................................................25 2.5.9 Denominator Statement .....................................................................................25 2.5.10 Denominator Exclusions ...................................................................................26