2023 MIPS Cost: Hemodialysis Access Creation Measure


This document details the methodology for the Hemodialysis Access Creation measure and should be reviewed along with the Hemodialysis Access Creation Measure Codes List file, which contains the medical codes used in constructing the measure.

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Measure Description

Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures.

The Hemodialysis Access Creation episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who undergo a procedure for the creation of graft or fistula access for long-term hemodialysis during the performance period. The measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 60 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.


Measure Rationale

In 2015, there were 124,114 newly reported cases of end-stage renal disease (ESRD), bringing the total number of people with ESRD to 703,243. Patients aged 65 and older accounted for over 207,000 of those cases of ESRD and accounted for approximately half of all individuals who received hemodialysis access for that year, a 22% increase from 2010. However, for new cases of ESRD, less than 20% begin hemodialysis using either a fistula or a graft, which confer decreased morbidity and mortality rates and lower cost.3 The United States Renal Data System (USRDS) 2017 Annual Data Report found that Medicare spent $33.9 billion on patients with ESRD, and when combined with the cost of Chronic Kidney Disease (CKD), a total of over $98 billion. For hemodialysis care, Medicare spent a total of $88,750 per patient per year, excluding unknown modalities, and $1,677 for vascular access procedures (procedures to place or create vascular accesses and procedures to maintain them).4

The Hemodialysis Access Creation episode-based cost measure was selected for development based on input from an expert clinician committee—the Peripheral Vascular Disease Management Clinical Subcommittee—because of its impact in terms of patient population and clinician coverage, and the opportunity for incentivizing cost-effective, high-quality clinical care in this clinical area. Based on the initial recommendations from the Clinical Subcommittee, the subsequent measure-specific clinician expert workgroup provided extensive, detailed input on this measure.


Measure Numerator

The cost measure numerator is the sum of the ratio of observed to expected5 payment-standardized cost to Medicare for all Hemodialysis Access Creation episodes attributed to a clinician. This sum is then multiplied by the national average observed episode cost to generate a dollar figure.


Measure Denominator

The cost measure denominator is the total number of episodes from the Hemodialysis Access Creation episode group attributed to a clinician.


Data Sources

The Hemodialysis Access Creation cost measure uses the following data sources:

  • Medicare Part A and B claims data from the Common Working File (CWF)
  • Enrollment Data Base (EDB)
  • Long Term Care Minimum Data Set (LTC MDS)6


Care Settings

Methodologically, the Hemodialysis Access Creation cost measure can be triggered based on claims data from: ambulatory/office-based care centers, outpatient (OP) hospitals, and ambulatory surgical centers (ASC).



The cohort for this cost measure consists of patients who are Medicare beneficiaries enrolled in Medicare fee-for-service and who undergo a procedure for the creation of graft or fistula access for long-term hemodialysis that triggers a Hemodialysis Access Creation episode.

The cohort for this cost measure is also further refined by the definition of the episode group and measure-specific exclusions (refer to Section 4).



1 Claim payments are standardized to account for differences in Medicare payments for the same service(s) across Medicare providers. Payment standardized costs remove the effect of differences in Medicare payment among health care providers that are the result of differences in regional health care provider expenses measured by hospital wage indexes and geographic price cost indexes (GPCIs) or other payment adjustments such as those for teaching hospitals. For more information, please refer to the “CMS Part A and Part B Price (Payment) Standardization - Basics" and “CMS Part A and Part B Price (Payment) Standardization - Detailed Methods” documents posted on the CMS Price (Payment) Standardization Overview page. (https://resdac.org/articles/cms-price-payment-standardization-overview).
2 Cost is defined by allowed amounts on Medicare claims data, which include both Medicare trust fund payments and any applicable beneficiary deductible and coinsurance amounts.
3 Malas, Mahmoud B., Joseph K. Canner, Caitlin W. Hicks, Isibor J. Arhuidese, Devin S. Zarkowsky, Umair Qazi, Eric B. Schneider, James H. Black, Dorry L. Segev, and Julie A. Freischlag. "Trends in Incident Hemodialysis Access and Mortality." JAMA Surgery 150, no. 5 (2015): 441-448.
4 United States Renal Data System, 2017 Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2017.
5 Expected costs refer to costs predicted by the risk adjustment model. For more information on expected costs and risk adjustment, please refer to Section 4.5.
6 For information on how LTC MDS data are used in risk adjustment, please refer to Section 4.5.

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