End stage renal disease - pediatric worksheet

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  • 1. PCPI Approved – August 2008 American Society of Pediatric Nephrology/Physician Consortium for Performance Improvement® American Society of Pediatric Nephrology The Physician Consortium for Performance Improvement® Pediatric End Stage Renal Disease Physician Performance Measurement Set PCPI Approved August 2008 © 2008 American Medical Association. All Rights Reserved. CPT® Copyright 2007 American Medical Association
  • 2. PCPI Approved—August 2008 American Society of Pediatric Nephrology/Physician Consortium for Performance Improvement® Work Group Members Pediatric End Stage Renal Disease Work Group Members Barbara Fivush, MD (Co-Chair) (pediatric nephrology) William Haley, MD (Co-Chair) (adult nephrology) Sharon Andreoli, MD (pediatric nephrology) Craig B. Langman, MD (pediatric nephrology) Eileen Brewer, MD (pediatric nephrology) Sharon A. Perlman, MD (pediatric nephrology) Leona Cuttler, MD (pediatric endocrinology) Paul Rockswold, MD, MPH (family medicine) Richard Goldman, MD (adult nephrology) Brad Warady, MD (pediatric nephrology) Stuart Goldstein, MD (pediatric nephrology) Steven J. Wassner, MD (pediatric nephrology) John Foreman, MD (pediatric nephrology) Work Group Staff American Society of Pediatric Nephrology Domenic Ruscio Jennifer Shevcheck Kathryn Schubert Renal Physicians Association Holly Owens Dale Singer American Medical Association Kerri Fei, MSN, RN Kendra Hanley, MS Karen Kmetik, PhD Shannon Sims, MD, PhD Consortium Consultants Rebecca Kresowik Timothy Kresowik, MD © 2008 American Medical Association. All Rights Reserved. 2 CPT® Copyright 2007 American Medical Association
  • 3. PCPI Approved—August 2008 American Society of Pediatric Nephrology/Physician Consortium for Performance Improvement® Table of Contents Purpose of Measures........................................................................................................................................................................ 3 Intended Audience and Patient Population....................................................................................................................................... 4 Measure Specifications..................................................................................................................................................................... 4 Measure Exclusions.......................................................................................................................................................................... 4 Measure #1: Plan of Care for Inadequate Hemodialysis ................................................................................................................. 5 Measure #2: Influenza Immunization ............................................................................................................................................... 8 Guideline Evidence Classification & Rating Schemes .................................................................................................................... 11 Physician Performance Measures (Measures) and related data specifications, developed by the Physician Consortium for Performance Improvement® (the Consortium), are intended to facilitate quality improvement activities by physicians. These Measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any physician who manages the care of a patient for a specific condition or for prevention. These performance Measures are not clinical guidelines and do not establish a standard of medical care. The Consortium has not tested its Measures for all potential applications. The Consortium encourages the testing and evaluation of its Measures. Measures are subject to review and may be revised or rescinded at any time by the Consortium. The Measures may not be altered without the prior written approval of the Consortium. Measures developed by the Consortium, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and American Medical Association, on behalf of the Consortium. Neither the Consortium nor its members shall be responsible for any use of these Measures. THE MEASURES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND © 2008 American Medical Association. All Rights Reserved Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, the Consortium and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specifications. THE SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND. CPT® contained in the Measures specifications is copyright 2007 American Medical Association. Purpose of Measures: © 2008 American Medical Association. All Rights Reserved. 3 CPT® Copyright 2007 American Medical Association
  • 4. PCPI Approved—August 2008 American Society of Pediatric Nephrology/Physician Consortium for Performance Improvement® These clinical performance measures, developed by the American Society of Pediatric Nephrology and the Physician Consortium for Performance Improvement® (PCPI), are designed for individual quality improvement. Unless otherwise indicated, the measures are also appropriate for accountability if appropriate methodological, statistical, and implementation rules are achieved. Intended Audience and Patient Population: These measures are designed for use by physicians and for calculating reporting or performance measurement at the individual physician level. When existing hospital-level or plan-level measures are available for the same measurement topics, the PCPI attempts to harmonize the measures to the extent feasible. The Pediatric End Stage Renal Disease measurement set was adapted from the Renal Physicians Association/Physician Consortium for Performance Improvement® (Adult) End Stage Renal Disease measurement set, with special consideration taken to ensure that the measures would be specific to the pediatric patient population. These measures are designed for pediatric nephrologists and for any other physicians who provide ongoing care for pediatric patients with end stage renal disease who are receiving maintenance dialysis. The PCPI also encourages the use of these measures by other health care professionals, where appropriate. Measure Specifications: The PCPI seeks to specify measures for implementation using multiple data sources, including paper medical record, administrative (claims) data, and particular emphasis on Electronic Health Record Systems (EHRS). Draft specifications to report on these measures for Pediatric End Stage Renal Disease using administrative (claims) data are included in this document. We have identified codes for these measures, including ICD-9 and CPT (Evaluation & Management Codes, Category I and where Category II codes would apply). Specifications for additional data sources, including EHRS, will be fully developed at a later date. Measure Exclusions: For process measures, the Consortium provides three categories of reasons for which a patient may be excluded from the denominator of an individual measure: • Medical reasons Includes: - not indicated (absence of organ/limb, already received/performed, other) - contraindicated (patient allergic history, potential adverse drug interaction, other) • Patient reasons Includes: - patient declined - economic, social, or religious reasons - other patient reasons • System reasons Includes: - resources to perform the services not available - insurance coverage/payor-related limitations - other reasons attributable to health care delivery system These measure exclusion categories are not available uniformly across all measures; for each measure, there must be a clear rationale to permit an exclusion for a medical, patient, or system reason. The exclusion of a patient may be reported by appending the appropriate modifier to the CPT Category II code designated for the measure: • Medical reasons: modifier 1P • Patient reasons: modifier 2P • System reasons: modifier 3P © 2008 American Medical Association. All Rights Reserved. 4 CPT® Copyright 2007 American Medical Association
  • 5. PCPI Approved—August 2008 American Society of Pediatric Nephrology/Physician Consortium for Performance Improvement® Although this methodology does not require the external reporting of more detailed exclusion data, the PCPI recommends that physicians document the specific reasons for exclusion in patients’ medical records for purposes of optimal patient management and audit-readiness. The PCPI also advocates the systematic review and analysis of each physician’s exclusions data to identify practice patterns and opportunities for quality improvement. For example, it is possible for implementers to calculate the percentage of patients that physicians have identified as meeting the criteria for exclusion. Please refer to documentation for each individual measure for information on the acceptable exclusion categories and the codes and modifiers to be used for reporting. Measures #1-2 in the Pediatric End Stage Renal Disease measurement set are process measures. For outcome measures, the PCPI specifically identifies all acceptable reasons for which a patient may be excluded from the denominator. Each specified reason is reportable with a CPT Category II code designated for that purpose. There are no outcome measures in the Pediatric End Stage Renal Disease measurement set. The PCPI continues to evaluate and likely will evolve its methodology for handling exclusions as it gains experience in the use of the measures. The PCPI welcomes comments on its exclusions methodology. Measure #1: Plan of Care for Inadequate Hemodialysis © 2008 American Medical Association. All Rights Reserved. 5 CPT® Copyright 2007 American Medical Association
  • 6. PCPI Approved—August 2008 American Society of Pediatric Nephrology/Physician Consortium for Performance Improvement® Pediatric End Stage Renal Disease This measure may be used as an Accountability measure. Measure Description Percentage of calendar months during the 12 month reporting period in which patients aged 17 years and younger with a diagnosis of ESRD receiving hemodialysis have a single-pool Kt/V ≥1.2 or have a single-pool Kt/V <1.2 with a documented plan of care for inadequate hemodialysis Measure Detail Numerator Number of patient calendar months during which patients have a single-pool Kt/V ≥1.2 OR have a single-pool Kt/V <1.2 with a documented plan of care for inadequate hemodialysis *A documented plan of care may include checking for adequacy of the AV access, increasing the blood flow, increasing the dialyzer size, increasing the time of dialysis sessions, increasing the number of days of dialysis, documenting residual renal function, documenting that patient has an inborn error of metabolism or is undergoing an alternate hemodialysis modality. Denominator Patient calendar months for all patients aged 17 years and younger with a diagnosis of ESRD and receiving hemodialysis Denominator None Exclusions Supporting The following evidence statements are quoted verbatim from the referenced clinical guidelines. Guideline Children should receive at least the delivered dialysis dose as recommended for the adult population. (NKF K/DOQI 2006 1 ) (Grade A Recommendation) Guideline Recommendations for Measuring and Expressing Hemodialysis Dose and for Minimally Adequate Hemodialysis in Adults Quantifying HD is the first step toward assessment of its adequacy. Fortunately, the intermittent rapid decrease in urea concentration during HD allows a relatively easy measurement of the dose. The delivered dose should be measured at regular intervals and no less than monthly. (NKF K/DOQI 2006) (Grade A Recommendation) The minimally adequate dose of HD given 3 times per week with Kr less than 2 mL/min/1.73m2 should be an spKt/V (excluding RKF) of 1.2 per dialysis. For treatment times less than 5 hours, an alternative minimum dose is a URR of 65%. (NKF K/DOQI 2006) (Grade A Recommendation) Measure Importance Relationship to Patients receiving hemodialysis must be monitored (by assessing Kt/V) regularly to ensure that their desired outcome dialysis dose is sufficient. A patient receiving thrice weekly hemodialysis whose Kt/V is less than 1.2 is not receiving adequate dialysis. This measure assesses whether the treating physician addressed a low Kt/V level. A plan of care (defined as checking for adequacy of the AV access, increasing the blood flow, increasing the dialyzer size, increasing the time of dialysis sessions, increasing the number of days of dialysis, documenting residual renal function, or documenting that patient has an inborn error of metabolism or is undergoing an alternate hemodialysis modality) should be documented by the physician for every time the Kt/V is less than 1.2. Opportunity for In 2005, of those patients with enough data elements to be included in the CPM ESRD Report, 12% © 2008 American Medical Association. All Rights Reserved. 6 CPT® Copyright 2007 American Medical Association
  • 7. PCPI Approved—August 2008 American Society of Pediatric Nephrology/Physician Consortium for Performance Improvement® Improvement had a Kt/V of <1.2 2 . Overall mortality rates for patients with pediatric end stage renal disease have increased 5% from 1991-2005 3 . Mortality rates for pediatric end stage renal disease patients receiving hemodialysis are the highest, compared to those receiving peritoneal dialysis or who have received kidney transplant. Ensuring that pediatric hemodialysis patients receive adequate dialysis dose may have a positive impact on morbidity and mortality. Technical Specifications: Administrative Data Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible population/denominator criteria. The specifications listed below are those needed for performance calculation. Additional CPT II codes may be required based on measure implementation. (ie, if measure is utilized in a reporting program). Additional information about CPT II codes is available at: http://www.ama-assn.org/ama/pub/category/10616.html Denominator Patient calendar months for all patients aged 17 years and younger with a diagnosis of ESRD and (Eligible Population) receiving hemodialysis ICD-9 Diagnosis Code: • 585.6- End stage renal disease AND CPT Procedure Code: • 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959 Numerator Number of patient calendar months during which patients have a single-pool Kt/V ≥1.2 OR have a single-pool Kt/V <1.2 with a documented plan of care for inadequate hemodialysis Report the CPT Category II code(s) designated for this numerator: Patients documented to have a Kt/V ≥1.2: • 3083F: Kt/V equal to or greater than 1.2 and less than 1.7 (Clearance of urea (Kt)/volume (V)) OR • 3084F Kt/V greater than or equal to 1.7 (Clearance of urea (Kt)/volume (V)) OR Patients who have a Kt/V <1.2 with a documented plan of care: • 3082F: Kt/V less than 1.2 (Clearance of urea (Kt)/volume (V)) AND • 0505F: Hemodialysis plan of care documented Denominator None Exclusions Technical Specifications: Electronic Health Record System Technical specifications for electronic health care record systems are under development. © 2008 American Medical Association. All Rights Reserved. 7 CPT® Copyright 2007 American Medical Association
  • 8. PCPI Approved—August 2008 American Society of Pediatric Nephrology/Physician Consortium for Performance Improvement® Technical Specifications: Prospective Data Collection Flowsheet Prospective data collection flow sheets are developed for measure sets after they are approved. References 1 National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Hemodialysis Adequacy. Update 2006. Available at: http://www.kidney.org/professionals/KDOQI/guidelines.cfm. Accessed: December 2007. 2 Centers for Medicare & Medicaid Services. 2006 Annual Report, End Stage Renal Disease Clinical Performance Measures Project. Department of Health and Human Services. Centers for Medicare & Medicaid Services, Office of Clinical Standards & Quality. Baltimore, MD. January 2007. 3 U. S. Renal Data System. USRDS 2007 Annual Data Report: Atlas of Chronic Kidney Disease and End Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Bethesda, MD. 2007. Measure #2: Influenza Immunization © 2008 American Medical Association. All Rights Reserved. 8 CPT® Copyright 2007 American Medical Association
  • 9. FOR PCPI VOTE—August 2008 American Society of Pediatric Nephrology/Physician Consortium for Performance Improvement® Pediatric End Stage Renal Disease This measure may be used as an Accountability measure. Measure Description Percentage of patients aged 6 months through 17 years with a diagnosis of ESRD and receiving dialysis seen for a visit between November 1 and February 15 of the one-year measurement period who have documented administration of influenza immunization OR patient reported receipt of an influenza immunization from another provider Measure Detail Numerator Patients who have documented administration of an influenza immunization OR patient reported receipt of influenza immunization from another provider *Children with renal disease should receive inactivated flu vaccine Denominator All patients aged 6 months through 17 years with a diagnosis of ESRD and receiving dialysis seen for a visit between November 1 and February 15 of the one-year measurement period Denominator Documentation of medical reason(s) for not receiving influenza immunization (eg, patient allergy, Exclusions other contraindication) Documentation of patient reason(s) for not receiving the influenza immunization (eg, patient/caregiver declined) Documentation of system reason(s) for not receiving the influenza immunization (eg, vaccine not available) Supporting The following evidence statements are quoted verbatim from the referenced clinical guidelines. Guideline Vaccination of all children aged 6 months—18 years should begin before or during the 2008-09 influenza season if feasible, but no later than during the 2009-10 influenza season. Vaccination of all children aged 5-18 years is a new ACIP recommendation. (CDC/ACIP, 2008 1 ) Children and adolescents at high risk for influenza complications should continue to be a focus of vaccination efforts as providers and programs transition to routinely vaccinating all children and adolescents. Recommendations for these children have not changed. Children and adolescents at higher risk for influenza complication are those: • aged 6 months—4 years • who have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological, or metabolic disorders (including diabetes mellitus) • who are immunosupressed (including immunosupression caused by medication or by human immunodeficiency virus) (CDC/ACIP, 2008) All children aged 6 months—8 years who have not received vaccination against influenza previously should receive 2 doses of the vaccine the first influenza season they are vaccinated. The second dose should be administered 4 or more weeks after the initial dose. (CDC/ACIP, 2008) Measure Importance Relationship to Vaccinating children with pediatric end stage renal disease is an important aspect of care in order to desired outcome potentially decrease hospitalization rates, morbidity, and mortality in this vulnerable population,. © 2008 American Medical Association. All Rights Reserved. 9 CPT® Copyright 2007 American Medical Association
  • 10. FOR PCPI VOTE—August 2008 American Society of Pediatric Nephrology/Physician Consortium for Performance Improvement® Opportunity for United States Renal Data System (USRDS) data show that between 2002-2005 only 30.1% of white Improvement pediatric end stage renal disease patients and 24.8% of African American pediatric end stage renal disease patients received the influenza immunization 2 . Infectious disease is a common reason for hospitalization, morbidity, and mortality among pediatric end stage renal disease patients. All-cause hospital admission rates for pediatric end stage renal disease patients was 14% higher in 2005 when compared to all-cause hospital admission rates for adults. Hospitalizations for infections are also higher in children with end stage renal disease (46%) than in adults. Technical Specifications: Administrative Data Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible population/denominator criteria. The specifications listed below are those needed for performance calculation. Additional CPT II codes may be required based on measure implementation. (ie, if measure is utilized in a reporting program). Additional information about CPT II codes is available at: http://www.ama-assn.org/ama/pub/category/10616.html Denominator All patients aged 6 months through 17 years with a diagnosis of ESRD and receiving dialysis seen for (Eligible Population) a visit between November 1 and February 15 of the one-year measurement period ICD-9 Diagnosis Code: • 585.6 AND CPT Procedure Code: • 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959 • 90963, 90964, 90965 Numerator Patients who have documented administration of an influenza immunization OR patient reported receipt of influenza immunization from another provider Report the CPT Category II code designated for this numerator: • 4274F: Influenza immunization administered or previously received Documentation of medical reason(s) for not receiving influenza immunization (eg, patient allergy, other contraindication) • Append modifier to CPT Category II code: 4274F-1P Documentation of patient reason(s) for not receiving the influenza immunization (eg, patient/caregiver Denominator declined) Exclusions • Append modifier to CPT Category II code: 4274F -2P Documentation of system reason(s) for not receiving the influenza immunization (eg, vaccine not available) • Append modifier to CPT Category II code: 4274F -3P Technical Specifications: Electronic Health Record System Technical specifications for electronic health care record systems are under development. © 2008 American Medical Association. All Rights Reserved. 10 CPT® Copyright 2007 American Medical Association
  • 11. FOR PCPI VOTE—August 2008 American Society of Pediatric Nephrology/Physician Consortium for Performance Improvement® Technical Specifications: Prospective Data Collection Flowsheet Prospective data collection flow sheets are developed for measure sets after they are approved. References 1 Centers for Disease Control and Prevention. Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP, 2008). MMWR Early Release 2008;57(July 17):1-60) 2 U. S. Renal Data System. USRDS 2007 Annual Data Report: Atlas of Chronic Kidney Disease and End Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Bethesda, MD. 2007. Guideline Evidence Classification & Rating Schemes Pediatric End Stage Renal Disease © 2008 American Medical Association. All Rights Reserved. 11 CPT® Copyright 2007 American Medical Association
  • 12. FOR PCPI VOTE—August 2008 American Society of Pediatric Nephrology/Physician Consortium for Performance Improvement® NKF K/DOQI Clinical Practice Guidelines and Clinical Practice Recommendations 2006 Update: Hemodialysis Adequacy 1 Strength of Recommendation: • Grade A: It is strongly recommended that clinicians routinely follow the guideline for eligible patients. There is strong evidence that the practice improves health outcomes. • Grade B: It is recommended that clinicians routinely follow the guideline for eligible patients. There is moderately strong evidence that the practice improves health outcomes. • CPR: It is recommended that clinicians consider the following guideline for eligible patients. The recommendation is based on either weak evidence or on the opinions of the Work Group and reviewers that the practice might improve health outcomes. References 1 National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Hemodialysis Adequacy. Update 2006. Available at: http://www.kidney.org/professionals/KDOQI/guidelines.cfm. Accessed: December 2007. © 2008 American Medical Association. All Rights Reserved. 12 CPT® Copyright 2007 American Medical Association