June 2022 EQRS News

The Centers for Medicare & Medicaid Services (CMS) has resumed the typical End Stage Renal Disease (ESRD) Quality Reporting System (EQRS) data submission schedule for monthly Clinical Data, Clinical Depression and Follow Up reporting and In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Attestations. The data submission schedule for these data is as follows:

EQRS Clinical Data: Opens for reporting on the first of the month and closes approximately two months after the end of the reporting month
Clinical Depression Screening and Follow Up: Opens for reporting on the first of January and remains open throughout the duration of the entire year and up through the last day in February of the following year
ICH CAHPS Attestation: Opens for submission on the first of January and remains open through the last day in February for the preceding calendar year (CY) attestations (e.g., CY 2022 attestations must be submitted in EQRS by the end of February 2023)

For the CY 2022 EQRS data submission deadlines, refer to page 4 of this Newsletter. For additional information, including exclusion criteria for the data listed above, refer to the ESRD Quality Incentive Program (QIP) Measure Technical Specifications available on CMS.gov: ESRD QIP PY 2023 Technical Specifications (CY 2021 ESRD PPS Final Rule) (cms.gov)

Register for the EQRS Town Hall

Join the ESRD Outreach, Communication and Training (EOCT) Team for a Town Hall event for information on various EQRS reporting activities.

Date: Thursday, June 23, 2022

Time: 2:00 p.m. – 3:00 p.m. Eastern Time (ET)

The following topics will be discussed:

EQRS Updates and Data Submission Deadlines
ESRD QIP Ultrafiltration Rate (UFR) Reporting Measure and UFR Reporting in EQRS
CMS-2728 and CMS-2746 Forms Overview and Tips
EQRS FAQs

Care Compare Dialysis Data Release on Medicare.gov

On April 27, 2022, CMS released new dialysis facility data on Care Compare on the Medicare.gov website. Through this website, patients and healthcare stakeholders can view and compare quality data about dialysis facilities. These data are organized into a series of measures from which CMS creates a star rating system that helps ensure safety, quality, and transparency among dialysis facilities. The star rating system also helps patients make educated decisions about where to get their dialysis treatments. To access the latest dialysis star ratings on Care Compare on the Medicare.gov website, go to: https://www.medicare.gov/care-compare/.

Additionally, CMS also released the Payment Year (PY) 2022 ESRD QIP public reporting files on April 27, 2022. These reporting files contain scoring and measure performance for the ESRD QIP measures for all eligible outpatient dialysis facilities in PY 2022. The public reporting files promote data transparency and, similar to the star rating system, are intended to help patients make informed decisions when selecting their dialysis facility. The PY 2022 ESRD QIP public reporting files are available on the CMS.gov Provider Data Catalog website for the following domain topics and quality reporting measures:

Patient & Family Engagement

ICH CAHPS: Individual measures and star rating of ICH CAHPS survey of patients’ experiences (i.e., kidney doctor’s communication and caring; dialysis center staff care and operations; providing information to patients; rating of kidney doctors, the dialysis center staff; the dialysis facility and overall star rating of ICH CAHPS survey of patients’ experiences)

Care Coordination

Standardized Readmission Ratio (SRR)
Standardized Hospitalization Ration (SHR)
Percentage of Prevalent Patients Waitlisted (PPPW)
Clinical Depression Screening and Follow-Up

Clinical Care

Kt/V Dialysis Adequacy (comprehensive)
Vascular Access:
- Standardized Fistula Rate (SFR)
- Long-term Catheter Rate
Standardized Transfusion Ratio (STrR)
Hypercalcemia
UFR

Safety

National Healthcare Safety Network (NHSN) Bloodstream Infection (BSI) in Hemodialysis Patients
NHSN Dialysis Event Reporting
Medication reconciliation (MedRec)

Medicare beneficiaries, facilities, and other stakeholders can find this information on Care Compare on the Medicare.gov website, as well as the Public Reporting & Certificates page on the ESRD QIP section of CMS.gov.

ECE Submission Process

CMS offers a process for dialysis facilities to request an extraordinary circumstances exception (ECE) when events occur that are beyond the control of the facility and impact regular operations. If an ECE is approved and granted by CMS, any impact to the facility’s performance caused by the extraordinary circumstance will not be factored into their ESRD QIP scores. ECE request forms can be submitted by any of the following ways:

Secured fax to: 877-789-4443
Emailed to: QRFormsSubmission@hsag.com
Managed File Transfer (MFT) to: QRFormsSubmission@hsag.com (uncheck “Require Registered Users”)

Additional information on the ECE policy and access to an ECE request form is available from the QualityNet website: https://qualitynet.cms.gov/esrd/esrdqip/participation#tab5.

ESRD QIP UFR Reporting Measure

CMS added the UFR Reporting Measure to the Clinical Care Domain of the ESRD QIP in PY 2020. CMS established the UFR measure as a reporting measure, meaning facilities are scored on the completeness of the data that are reported and not on the actual performance of the measure, nor the UFR values themselves. The UFR measure encourages facilities to monitor and accurately report ultrafiltration data in EQRS. CMS has not established a performance threshold for the UFR measure; therefore, the patient’s nephrologist and facility staff must determine an optimal and safe UFR for each individual patient.

Facilities are scored on the UFR measure based on the number of months that the facility reports all required data elements for UFR in EQRS for all hemodialysis sessions during the week of the monthly Kt/V lab draw for that clinical month for each eligible patient. Additionally, successful UFR reporting by the facility includes the following data elements to be entered into EQRS on the Manage Clinical screen:

Location of Data Field within the Manage Clinical screen	Data Field
*Adequacy Section	Kt/V Date
	Pre and Post Dialysis Weight
	Delivered Minutes of BUN Hemodialysis Session
	Total Number of Dialysis Sessions During the Clinical Month
**Ultrafiltration Section	Session UF Date
	Session UF Pre and Post Dialysis Weight
	Session UF Delivered Minutes

*UFR data elements for the treatment day of the Kt/V lab draw are entered in the Adequacy section.
**UFR data elements for all remaining treatments (other than the treatment day of the Kt/V lab draw) are entered in the Ultrafiltration section.

From the Chat Box

Question: How should I enter ultrafiltration (UF) data on patients in EQRS?

Answer:

The UF data fields are located under the Manage Clinical screen in EQRS. On the Manage Clinical screen in the Adequacy section, enter the UF data elements for the actual treatment day that the Kt/V lab value was drawn. Next, in the Ultrafiltration section, enter the UF data elements for the remaining treatments received during the week that the Kt/V lab was drawn. UFR data elements do not need to be reported in EQRS for any other week besides the week of the Kt/V lab draw. The reported UFR data elements may not necessarily fall within the same clinical month.

Example 1: A patient receives treatment on Monday, Wednesday and Friday, and a Kt/V lab value is drawn on Monday. Enter the UF data elements for Monday in the Adequacy section and the Wednesday and Friday UF data elements in the Ultrafiltration section on the Manage Clinical screen.

Example 2: A patient receives treatment on Tuesday, Thursday and Saturday, and the Kt/V lab value is drawn on Saturday. Enter the UF data elements for Saturday in the Adequacy section and the UF data elements for the Tuesday and Thursday preceding the Saturday that the Kt/V lab was drawn in the Ultrafiltration section on the Manage Clinical screen.

Example 3: A patient receives treatment on Tuesday and the Kt/V lab value is drawn on that Tuesday, but the patient does not receive any other treatments during the week. Enter the UF data elements for that Tuesday in the Adequacy section on the Mange Clinical screen. No additional UF data elements are required since the patient only received treatment on Tuesday.

How to Route Questions

Please do NOT include patients’ Protected Health Information (PHI) and Personally Identifiable Information (PII) including patient name, date of birth, social security number, Medicare Beneficiary Identifier, and Health Insurance Claim Number, etc., when submitting a ticket and/or inquiry to the QualityNet Q&A Tool, CCSQ Service Center and ESRD Network. Any disclosure of PHI or PII should only be in accordance with, and to the extent permitted by, the Health Information Portability and Accountability Act (HIPAA), the HIPAA Privacy and Security Rules, and other applicable laws.

Please note: the EQRS identification number is the ONLY acceptable patient identifier when submitting a ticket and/or inquiry to the QualityNet Q&A Tool, CCSQ Service Center and ESRD Network.

The table below contains contact information organized by question type:

Question or Issue Type	Contact Information
EQRS & ESRD QIP Questions: General ESRD QIP questions General EQRS data entry questions Centers for Medicare & Medicaid Services (CMS) reporting requirement questions	*QualityNet Question & Answer (Q&A) Tool: https://cmsqualitysupport. servicenowservices.com/qnet_qa Note:* To access EQRS training and/or educational materials, visit the Education page from MyCROWNWeb.org.
*EQRS System-related Questions or Issues:* Healthcare Quality Information System (HCQIS) Access Roles and Profile (HARP)/EQRS account lockout EQRS reporting errors and/or system issues (i.e., making modifications on a submitted CMS-2728 or CMS-2746 form, multiple Patient IDs, batching errors, etc.) Other technical issues with EQRS not working properly	*The Center for Clinical Standards and Quality (CCSQ) Service Center:* CCSQ Service Center hours of operation are Monday through Friday 8 a.m.-8p.m. ET. The CCSQ Service Center can be reached via: Phone: (866) 288-8912 Email: qnetsupport-esrd@cms.hhs.gov CCSQ Support Central (to create and track a ticket): https://cmsqualitysupport.servicenowservices.com/ccsq_support_central
*ESRD Network Assistance with:* Editing the View Patient Demographics screen in EQRS to complete a missing or saved CMS-2728 form when the facility no longer has access to edit this screen Adding a date of death and/or primary death code to the View Patient Demographics screen in EQRS for patients who have been discharged from your facility for over 90 days Resolving possible duplicate or near match patients in EQRS Quality Improvement Activities (QIAs) Patient grievances and/or facility concerns	*ESRD Network Contact Information: https://esrdncc.org/en/ESRD-network-map/*

Note: To access EQRS training and/or educational materials visit the Education page from MyCROWNWeb.org.

EQRS Data Submission Deadlines

Dialysis facilities must meet the EQRS data deadlines listed below to meet CMS reporting requirements. Failure to complete the submission of data by the deadlines listed in this announcement puts your facility at risk for an ESRD QIP payment reduction. The data submission deadline applies to all collection types (Hemodialysis and Peritoneal Dialysis) and to all submission methods. CMS strongly recommends that facilities complete large data submissions and audit batch submitted data prior to data submission deadlines.

CY 2022 data will support the PY 2024 ESRD QIP. For additional details, please refer to the CY 2022 ESRD Prospective Payment System final rule, available from the Federal Register.

2022 EQRS Data Submission Schedule for: EQRS Clinical Data
Reporting Months	Data Submission Deadline
April 2022	June 30, 2022 at 11:59 PM PT
May 2022	August 1, 2022 at 11:59 PM PT
June 2022	August 31, 2022 at 11:59 PM PT
July 2022	September 30, 2022 at 11:59 PM PT
August 2022	October 31, 2022 at 11:59 PM PT
September 2022	November 30, 2022 at 11:59 PM PT
October 2022	January 2, 2023 at 11:59 PM PT
November 2022	January 31, 2023 at 11:59 PM PT
December 2022	February 28, 2023 at 11:59 PM PT

2022 EQRS Data Submission Schedule for:

Clinical Depression Screening and Follow Up
ICH CAHPS Facility Attestation

Reporting Months

Data Submission Deadline

January 2022 – December 2022
(All months in 2021)

February 28, 2023 at 11:59 PM PT

CY 2022 data will support the PY 2024 ESRD QIP. For additional details, please refer to the CY 2022 ESRD PPS final rule, available from the Federal Register.

The information included as part of this newsletter is current as of the date of release.