Quality Insights Renal Network 4 
A Periodic Newsletter from Quality Insights Renal Network 4 | www.qirn4.org
In This Issue
Alerts and Recalls
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QIRN 4 Staff
Executive Director
  
Quality Improvement Director
  
Quality Improvement Coordinator
  
Patient Services Director
  
Patient Services Coordinator
  
Data Manager
  
Administrative Assistant
May 2014 
Greetings from QIRN 4
Quality Insights Renal Network 4 (QIRN 4) is committed to providing valuable resources that help improve the quality of renal care in Pennsylvania and Delaware. 
 
We encourage you to visit our Web site for the most up-to-date information or to contact us with questions, comments or suggestions. 
 
Sincerely,
Your QIRN 4 Team
Final Measure Specifications for the PY 2016 ESRD Quality Incentive Program (QIP): Monthly Spotlight
For the next few months, QIRN 4 will be featuring monthly Clinical Measure and Reporting Measure guidelines to assist you in your quality improvement efforts. Please contact us with any questions. 
  
Clinical Measures -

 

Measure Description: Percentage of Medicare patients with a mean hemoglobin value greater than 12 g/dL.

 

Numerator: Number of Medicare patients at the facility during the measurement period included in the denominator with a mean hemoglobin greater than 12 g/dL.

 

Denominator: Number of Medicare patients at the facility during the measurement period. Exclusions:
  1. Patients younger than 18
  2. Patients on dialysis for less than 90 days
  3. Patients who have not been treated with erythropoiesis stimulating agents (ESAs) during the claim month
  4. Hemoglobin values less than 5
  5. Hemoglobin values greater than 20
  6. Patients not on chronic dialysis as defined by a completed 2728 form, a REMIS/CROWNWeb record, or a sufficient amount of dialysis reported on dialysis facility claims
  7. Patients with missing data
Minimum Claims: 4 months

 

Data Source(s):  
  1. Medicare claims
  2. REMIS, CROWNWeb, and other CMS ESRD administrative data (form 2728 to obtain the diagnosis date of ESRD and date of birth)
Additional Information:   
  1. Last valid claim of the month is used for calculation.
  2. When hematocrit is reported on a claim, it is changed to hemoglobin by dividing by 3 and rounding to 1 decimal place.
  3. All hemoglobin levels should be rounded to 1 decimal place.
  4. No interpolation between claims for peritoneal dialysis patients.
  5. The value reported by the facility is used, but the facility may obtain this value from an external source. 
Reporting Measures -

Measure Description: Number of months for which facility reports ESA dosage (as applicable) and hemoglobin/hematocrit for each Medicare patient at least once per month.

 

Exclusions:  
  1. Facilities with a CMS certification on or after July 1, 2014
  2. In-center hemodialysis patients treated at a facility fewer than 7 times during claim month
  3. Home dialysis patients for whom a facility does not submit a claim during the claim month
  4. Facilities treating one or zero patients during the performance period who are (i) in-center Medicare patients who have been treated at least 7 times by the facility during the reporting month; or (ii) home dialysis Medicare patients for whom the facility submits a claim during the reporting month
  5. Patients not on chronic dialysis as defined by a completed 2728 form or a REMIS/CROWNWeb record

Data Source(s):

 

  1. Medicare Claims
  2. REMIS, CROWNWeb, and other CMS ESRD administrative data (form 2744 to obtain certification date)

 

Additional Information:

 

  1. Hemoglobin value of 99.99 is not considered valid for purposes of measure. Note: we will not penalize facilities for using the default 99.99 value for a patient in his/her first month of treatment at that facility.
  2. The hemoglobin/hematocrit reported by the facility is used. The facility may obtain this value from an external source.
  3. No ESA dosage need be recorded if patient is not treated with ESAs.
  4. ESA dosage must be reported via HCPCS codes and corresponding units, as applicable.
  5. If a facility treats one of the following patients during the performance period, the facility can attest to this fact in CROWNWeb to not be scored on this measure:
    • an in-center Medicare patient who has been treated at least 7 times by the facility during a reporting month; or
    • a home dialysis Medicare patient for whom the facility submits a claim during a reporting month.
CROWNWeb Training Resources 
The following resources from Project CROWNWeb include training tutorials, frequently asked questions, quick start guides and much more to help you become fluent with the CROWNWeb system. 
  
  
NHSN Report Fact Sheet
The Centers for Disease Control and Prevention (CDC) has created this guide to assist in the creation and understanding of National Healthcare Safety Network (NHSN) reports for Centers for Medicare & Medicaid Services (CMS) ESRD Quality Improvement Projects (QIP).
 
CDC Infection Prevention Tools
Check out the CDC's Web site for the latest training videos, print materials, fact sheets, checklists and more on the topic of Infection Prevention.
  
Interested in Living Donation?

In response to the scarcity of kidneys for transplantation, relatives, friends and even individuals with no prior relationship are choosing to serve as living donors for the growing number of people on the national organ transplant waiting list. A living donor can save and/or greatly improve the quality of life of a transplant candidate. Living Donation: Information You Need to Know, is a guide developed by the United Network for Organ Sharing (UNOS) and includes information on the living donation process, data and additional resources.  

 
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Quality Insights Renal Network 4
 630 Freedom Business Center, Suite 116
King of Prussia, PA 19406
610-265-2418
800-548-9205 (patients only) 
610-783-0374 (fax)
This material was prepared by Quality Insights Renal Network 4 under contract with the Centers for Medicare & Medicaid Services (CMS). The contents do not necessarily reflect CMS policy. Publication No. ESRD4-MV-051914 App. 05/14

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