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  2. CQM-7635

Controlling High Blood (CMS165v13) - ESRD/Transplant Exclusions

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    • Resolution: Answered
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    • Gregg Weinberg
    • 6462078848
    • Curana Health
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      Thank you for your inquiry regarding CMS165v13 (2025 Performance Period). The measure logic specifies that diagnoses such as ESRD (End Stage Renal Disease), Kidney Transplant Recipient, and CKD (Chronic Kidney Disease) Stage 5 must overlap the measurement period to qualify for exclusion. If the diagnosis is resolved before the start of the measurement period, it does not meet the exclusion criteria.

      While these diagnoses are chronic and remain relevant over time, the logic requires that they be active during the measurement period. A diagnosis of ESRD, CKD Stage 5, or Kidney Transplant Recipient that began prior to the measurement period should still be considered active, as these conditions typically do not resolve. As such, patients with these diagnoses, even if documented before the measurement year, should be excluded since these conditions don’t have an end date, ensuring overlap with the measurement period.
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      Thank you for your inquiry regarding CMS165v13 (2025 Performance Period). The measure logic specifies that diagnoses such as ESRD (End Stage Renal Disease), Kidney Transplant Recipient, and CKD (Chronic Kidney Disease) Stage 5 must overlap the measurement period to qualify for exclusion. If the diagnosis is resolved before the start of the measurement period, it does not meet the exclusion criteria. While these diagnoses are chronic and remain relevant over time, the logic requires that they be active during the measurement period. A diagnosis of ESRD, CKD Stage 5, or Kidney Transplant Recipient that began prior to the measurement period should still be considered active, as these conditions typically do not resolve. As such, patients with these diagnoses, even if documented before the measurement year, should be excluded since these conditions don’t have an end date, ensuring overlap with the measurement period.
    • CMS0165v13
    • We are trying to ensure that we can safely exclude patients with ESRD, CKD or renal transplant ICD10s from the measure if those diagnoses were documented prior to the measurement year.

      Can you please clarify whether ESRD/Transplant diagnosis are acceptable exclusions if they occur before the measurement year. If a patient has a renal transplant, ESRD or CKD  ICD10 in their chart that is dated prior to measurement period is that adequate for exclusion from the denominator?

      The flow and narrative clearly indicate that such evidence can be present before or during the measurement year. 

      Denominator Exclusions
      The Denominator Exclusions criteria identify a subset of the Denominator population by excluding patients in hospice care for any part of the measurement period; patients with a diagnosis of pregnancy during the measurement period; patients who had evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period;

      However, the following would seem to indicate that the diagnoses for ESRD, Transplant. and chronic kidney disease must overlap the measurement period.

      Pregnancy or Renal Diagnosis

      •  
      • ( ["Diagnosis": "Pregnancy"]
        union ["Diagnosis": "End Stage Renal Disease"]
        union ["Diagnosis": "Kidney Transplant Recipient"]
        union ["Diagnosis": "Chronic Kidney Disease, Stage 5"] ) PregnancyESRDDiagnosis
        where PregnancyESRDDiagnosis.prevalencePeriod overlaps "Measurement Period"  

       
      Let me say the following, it is clear from the logic and from a previous response to a similar question that the diagnoses for renal/transplant must overlap the measurement period.  My question really is: is that logic correct? Or has the constraint related to pregnancy needing to overlap with the measurement been erroneously apply to renal disease and transplant state?  

      It seems to me the intent of the exclusion is to exclude patient's with a history of these diseases.  Every word in the narrative and flow says "evidence of...before or during the measurement period."  Once a renal transplant patient always a renal transplant patient so why is it necessary for the diagnosis to overlap with the measurement period while at the same time encounters for renal disease and procedures can occur on or before the end of the measurement period. 

      • End Stage Renal Disease Encounter *
      • ["Encounter, Performed": "ESRD Monthly Outpatient Services"] ESRDEncounter
        where ESRDEncounter.relevantPeriod starts on or before end of "Measurement Period" 
      • End Stage Renal Disease Procedures *
      • ( ["Procedure, Performed": "Kidney Transplant"]
        union ["Procedure, Performed": "Dialysis Services"] ) ESRDProcedure
        where end of Global."NormalizeInterval" ( ESRDProcedure.relevantDatetime, ESRDProcedure.relevantPeriod ) on or before end of "Measurement Period" 

       

      It does not make logical sense to allow these encounters for the same disease processes to occur at any point but limit when the diagnoses can occur.  I think clarification from the measure steward might be in order.

            AIR EC eCQM Team AIR EC eCQM Team
            gsw8 Gregg Weinberg
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