WCHQ Ambulatory Measure Specification
WCHQ 26 – CKD Care in Stages I, II and III – Annual eGFR Test
Measurement Period: 01/01/2016 – 12/31/2016
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
Measure Description
The percentage of patients age 18 through 85 years of age with Stage I, II, or III Chronic Kidney Disease (CKD) or Chronic Kidney Disorder who had the following during the 12-month measurement period:
1. An eGFR (Estimated Glomerular Filtration Rate) test annually
Disclaimer: Measures reported by WCHQ healthcare organizations represent a specific aspect of care in relation to an evidence-based standard, but are not clinical guidelines and do not establish standards of care.
All providers should have an individual care plan established with their patient.
General Information/Rationale
Chronic kidney disease (CKD) is a major public health problem. Improving outcomes for people with CKD requires a coordinated world-wide approach to prevention of adverse outcomes. Interventions during the earlier stages of kidney disease includes evaluation and management of co-morbid conditions, slowing progression of kidney disease, cardiovascular disease risk reduction, preventing and treating complications of CKD.
High blood pressure can be either a cause or a consequence of CKD. The appropriate evaluation and management of high blood pressure remains a major component of the care of patients with CKD. Cardiovascular disease is the leading cause of death in patients with chronic kidney disease, regardless of the stage of kidney disease. All patients with chronic kidney disease should undergo assessment of cardiovascular disease risk factors.
References:
National Kidney Foundation Clinical Practice Guidelines for the Treatment of Chronic Kidney Disease (2012). Retrieved March 2014 from: http://www.kdigo.org/clinical_practice_guidelines/ckd.php
Definitions
12 Months: Measurement Period
24 Months: Measurement Period + Prior Year
Office Visit: Office visit in an outpatient, non-urgent care setting
PCP: For WCHQ measure purposes, a primary care provider is defined as any General Practice, Internal Medicine, Family Practice, Pediatrics (MD, DO, PA, NP) and any other practitioners identified by the healthcare system as primary care practitioners. The rationale for the additional practitioner(s) must be documented and must be applied consistently across all preventive care and chronic care measures by the organization.
· Measure Specific Specialist: As part of the denominator population for this measure visits to a Cardiologist, Endocrinologist, or a Nephrologist for all patients may be included as an office visit.
· Age Range 18-85: Patients born between 01/01/1931 and 01/01/1998.
Denominator Description
Adults, whose age at the beginning of the one year measurement period is at least 18 and whose age at the end of the one year measurement period is less than 86 and who are alive as of the last day of the Measurement Period. Expired patients for whom a specific date of expiration cannot be found are excluded from the denominator population.
The rationale for the denominator population is built from the following criteria:
[Question 1] – Is this a patient with the disease or condition?
[Question 2] – Is this a patient whose care is managed within the physician group?
[Question 3] – Is this a patient currently managed in our system?
Encounter dataPatients eligible for inclusion in the denominator include:
[Question 1] – Is this a patient with the disease, or condition?
Criteria 1: Identify patients with a diagnosis of Stage I or II or III CKD through ICD-9 Codes
a. Those who had a minimum of two CKD coded (including any diagnoses coded for the visit) – (Table CKD1-1) office visits (Table CKD1-3), with any provider (MD, DO, PA, NP) in the Physician Group with different dates of service in an ambulatory setting during the last 24 Months [Measurement Period + Prior Year]
OR
Criteria 2: Identify patients with a diagnosis of a Chronic Kidney Disorder (not CKD)
b. Those who had a minimum of two chronic kidney disorder coded (including any diagnoses coded for the visit) – (Table CKD1-2) office visits (Table CKD1-3), with any provider (MD, DO, PA, NP) in the Physician Group with different dates of service in an ambulatory setting during the last 24 Months [Measurement Period + Prior Year]
Denominator Exclusions:
a. The Physician Group should exclude from the eligible population all patients diagnosed with any of the following:
1. Patients with Stage IV or V CKD or ESRD identified by one of the following:
1. One Stage IV or V CKD or ESRD coded encounter (any type of visit to any service) (Table CKD1-4) during the last 24 months [measurement period + prior year]
2. One Stage IV or V CKD or ESRD diagnosis from an ICD-9 diagnosis-based problem list (Table CKD1-4)
3. Those with two diagnoses of 585.9 OR one diagnosis of 585.1, 585.2 or 585.3 and one diagnosis of 585.9 (when 585.9 is the most recent diagnosis). These patients must also have the two most recent consecutive eGFR’s with results of less than 30 on different dates of service, a minimum of 90 days apart within the 12 month timeframe [Measurement Period].
a. Organizations that have two eGFR results electronically for every patient (one with African American component and one without) and have race available within a discreet field should use the race field to determine which eGFR result to include in the CKD measure. When the race field is not populated the non-African American eGFR should be included by default. Organizations who routinely have one eGFR result electronically and provide manual eGFR calculation information for their providers to make the determination based on race should always report the default (non-African American) eGFR.
b. If multiple ethnic groups are chosen within the discreet race field and “African American” is selected as one of the ethnic groups, the African American value should be used.
c. If Multiracial is chosen within the discreet race field and “African American” is not specifically indicated report the default (non-African American) eGFR.
[Question 2] – Is this a patient whose care is managed within the physician group?
Patients who had at least two office visits (Table CKD1-3), regardless of diagnosis code, on different dates of service, to a PCP and/or Cardiologist, Endocrinologist, or Nephrologist in the past 24 months. If the Cardiologist, Endocrinologist or Nephrologist is not considered a PCP, at least one of the two office visits must be to a PCP.
[Question 3] – Is this a patient currently managed in our system?
Those who had at least one office visit (Table CKD1-3), regardless of diagnosis code, with a PCP and/or Cardiologist, Endocrinologist, or Nephrologist during the last 12 Months [Measurement Period].
CKD Care in Stages I, II, and III - Final 2016
This specification is updated annually; refer to previous versions for coding and other changes
13
WCHQ Ambulatory Measure Specification
WCHQ 26 – CKD Care in Stages I, II and III – Annual eGFR Test
Measurement Period: 01/01/2016 – 12/31/2016
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
NUMERATOR DESCRIPTIONS1. An eGFR (Estimated Glomerular Filtration Rate) annually for all patients in the measure
This measure assesses the percentage of patients who had one or more eGFR tests within the last 12 Months [Measurement Period] as demonstrated through any of the following:
1. Administrative Data, which can include:
a) Internal or external eGFR tests extracted electronically and requiring Test Date
2. Medical Record Review (refer to Medical Record Review for Numerator Inclusion/Denominator Exclusion section)
NOTES:
· A CPT Code alone will not provide an eGFR test. It is a calculated rate derived from the MDRD (Modification of Diet in Renal Disease) The MDRD Study Equation can be found at the following reference: http://www.kidney.org/professionals/KLS/GFR.cfm#8
· CPT Codes 80048, 80053, 80069, 82565 and possibly others are lab panels that may contain an eGFR component. Use of one of these CPT codes alone cannot define the eGFR calculation rather the specific eGFR Test Name or ID included within the lab panel will need to be identified to isolate the eGFR.
· In cases where an eGFR result is not available because it cannot be calculated for any reason, excludes that eGFR test from counting as numerator compliant.
Internally Developed Codes – Data Translation/Mapping RequirementsIf a medical group utilizes internally generated codes to identify specific services or events required for a given WCHQ performance measure, the group may translate or map the information to the WCHQ performance measurement specifications. The medical group must assure that the internally generated code matches the clinical specificity of the standard (ICD-9, CPT) codes included in the WCHQ performance measurement specifications.
In order to use internally developed codes for WCHQ performance measure reporting, the medical group needs to document the translation/mapping to the codes in the specifications. This documentation should include the internally generated code, a description of the internally developed code, any additional clinical information for the internally developed code, and the equivalent standard code with description from the WCHQ performance measurement specifications. Once the translation/ mapping documentation is established, the medical group’s WCHQ performance measurement team must review the mapping on a yearly basis and document that internally developed codes have not changed and are being used in the manner described in the translation/ mapping document.
The medical group must have documented processes in place for adding codes to the medical group’s administrative data system and procedures to implement the internally developed codes.
Medical Record Review for Numerator Inclusion/Denominator Exclusion
If appropriate, and/or when necessary, every organization may complement their electronic capture of patient medical history with electronic or manual record review. The following criteria apply only to data captured/reviewed during medical record review.
For WCHQ Chronic Condition Measures, proof of Numerator compliance requires:
· Date test was performed.
Denominator Exclusion
For all WCHQ Measures, proof of Denominator exclusion requires:
ü Existence of exclusion criteria.
This data may be retrieved, in whole or in part, from any of the following:
· Notation in Progress Note
· Notation in Medical History or Surgical History
· Flag/Field in Electronic Medical Record
· Documentation in patient chart
REQUIRED DATA SUBMISSION FIELDSFields required for data submission for this measure depend upon the methodology used. The fields are as follows:
TOTAL POPULATION METHODOLOGY:
· Population Denominator (N) (Patients 18-85 years of age with Stage I, II, or III Chronic Kidney Disease (CKD) or Chronic Kidney Disorder)
· Numerators
1. An eGFR (Estimated Glomerular Filtration Rate) test annually
Upon entry of these numbers, the rate is automatically calculated
FIELDS REQUIRED FOR MEASURE VALIDATIONValidation of this measure will require patient level data files for Administrative Data and/or for Manual Review. The following indicates fields needed for validation, which may be helpful to consider when querying the measure:
Denominator Data File fields:
1. Patient Identifier (can be medical record number or other ID)
2. Office Visit Dates
3. Provider Specialty
4. Patient Date of Birth
5. Chronic Kidney Disease or Chronic Kidney Disorder Codes
6. Stage IV, V, and ESRD Exclusion Codes
Numerator Data File fields:
1. eGFR within the last 12 months
· Patient Identifier
· Lab Date(s) of Service (identify whether collection date versus test date)
· Lab ID Code(s) or Equivalent Test Name
· eGFR Test Result
Appendix A
Primary Payer
In keeping with the changing atmosphere of quality measurement and reporting, WCHQ would like for participating organizations to include the primary payer source with their data submissions for the ambulatory care measures.
The primary payer source should be identified in the denominator upon answering the question, “Is this patient current in our system?” Once it has been determined that a patient is current because of a visit to their physician within the specified time period (12 months for chronic care measures and 24 months for preventive care measures), the payer should be “pulled” into the query. The primary payer should be the payer at the most recent office visit within the measurement period.
There will be four categories of primary payer that will need to be submitted to WCHQ via the data submission tool: Medicare FFS, Medicaid (all types), Commercial (including Medicare HMO) and Uninsured/Self-Pay. The raw numbers for the denominator and numerator should be included for all three types of data submission, total population, hybrid, and sample.
Rationale
Opportunities exist for WCHQ to collect and report data on specific populations, like the Medicare population, through grant applications to begin to understand the disparities in quality of care. The purpose of this is to begin to understand the challenges of putting in additional data elements and complexities of data display for public reporting. At this time, the primary payer information will not be publicly reported.
Definitions:
Commercial: All plans not Medicaid or Medicare FFS (Includes VA, DoD, etc.)
FFS Medicare: FFS plans, not Medicare HMO (Medicare Railroad is FFS Medicare)
Medicaid: All Medicaid plans including those managed by commercial plans
Uninsured: Self-pay individuals
Appendix B
Table CKD1-1: Code to Identify CKD – Stages I, II, and III
ICD-9-CM Diagnosis Codes / Description585.1 / Chronic kidney disease, stage I
585.2 / Chronic kidney disease, stage II
585.3 / Chronic kidney disease, stage III (moderate)
585.9 / Chronic kidney disease, unspecified
Effective 10/01/2015
ICD-10-CM Diagnosis Codes / DescriptionN18.1 / Chronic kidney disease, stage 1
N18.2 / Chronic kidney disease, stage 2 (mild)
N18.3 / Chronic kidney disease, stage 3 (moderate)
N18.9 / Chronic kidney disease, unspecified
Table CKD1-2: Codes to Identify Other Types of Chronic Kidney Disorders
ICD-9-CM Diagnosis Codes / Description581.81 / Nephrotic syndrome in diseases classified elsewhere
582.9 / Chronic glomerulonephritis with unspecified pathological lesion in kidney
583.81 / With unspecified pathological lesion in kidney
588.xx / Disorders resulting from impaired renal function
588.0 / Renal osteodystrophy
588.1 / Nephrogenic diabetes insipidus
588.81 / Secondary hyperparathyroidism (of renal origin)
588.89 / Other specified disorders resulting from impaired renal function
588.9 / Unspecified disorder resulting from impaired renal function
753.0 / Renal agenesis and dysgenesis
753.1x / Congenital anomalies of urinary system
753.10 / Cystic kidney disease unspecified
753.11 / Congenital single renal cyst
753.12 / Polycystic kidney unspecified type
753.13 / Polycystic kidney autosomal dominant
753.14 / Polycystic kidney autosomal recessive
753.15 / Renal dysplasia
753.16 / Medullary cystic kidney
753.17 / Medullary sponge kidney
753.19 / Other specified cystic kidney disease
Effective 10/01/2015