September 2022 EQRS News

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In This Issue:

CY 2023 ESRD PPS Proposed Rule

Register for the EQRS Town Hall

EQRS Data Management Guidelines

New Features in EQRS

From the Chat Box

How to Route Questions

EQRS Data Submission Deadlines


Download the PDF.


View past Newsletters.


Upcoming Events:

New User Training

  • September, 20, 2022 • 2:00-3:30 PM ET

Web Resources:

MyCROWNWeb Website

Data Management Guidelines

Education

Conditions for Coverage for ESRD Facilities

ESRD Help


CY 2023 ESRD PPS Proposed Rule

On June 28, 2022, the Calendar Year (CY) 2023 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) Proposed Rule was published on the Federal Register website. Each year, the Center for Medicare & Medicaid Services (CMS) issues a proposed rule to update Medicare payment policies and rates under the PPS. Additionally, the proposed rule contains proposed updates for the ESRD Quality Incentive Program (ESRD QIP) requirements and includes requests for information on topics relevant to the ESRD QIP. This year the proposed rule requested information on quality indicators for home dialysis patients, principles for measuring healthcare quality disparities and potential future inclusion of two social drivers of health measures, as well as proposed refinements to the ESRD Treatment Choices Model. For more information, click on the following links:


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, September 8, 2022
Time: 2:00 p.m. – 3:00 p.m. Eastern Time (ET)

The following topics will be discussed:

  • EQRS Data Submission Deadlines and announcements
  • EOCT Announcements
  • New EQRS features:
    • Vaccination Module
    • Admission in Support of Transplant feature
    • Parathyroid Hormone (PTH) reporting fields
  • EQRS FAQs


EQRS Data Management Guidelines

The EQRS Data Management Guidelines outline and detail the standardized data management processes created, reviewed, and approved by CMS. EQRS users can use these guidelines when conducting and overseeing data entry activities and reporting efforts. The EQRS Data Management Guidelines document is updated annually to align with system releases, program policy, and CMS data quality goals. In August 2022, the guidelines were updated and reposted on the Home page on www.MyCROWNWeb.org and is available here: https://mycrownweb.org/?smd_process_download=1&download_id=6011.


New Features in EQRS

Vaccination Module:

On August 8, 2022, CMS added a new Vaccination Module on the Manage Patient screen in EQRS. Dialysis facilities are required to enter any new patient vaccination data for Hepatitis B, Influenza, and Pneumococcal vaccinations on the Manage Patient screen under the new Vaccinations tab (displayed in Figure 1 below) in EQRS. Facilities can enter vaccination data at any time after a patient is admitted to the facility and can view and edit vaccination data entered by facilities where the patient was previously admitted. Additionally, the most recent vaccination records will be migrated from the Manage Clinical screen to the new vaccination screens up until October 1, 2022. Starting on *October 1, 2022, the vaccination fields will no longer appear on the Manage Clinical screen in EQRS.

This new EQRS reporting process for vaccinations is an event-based reporting process. A vaccination event occurs anytime that a patient:

  • Receives a vaccine dose administered by the reporting facility
  • Receives a vaccine dose by an outside provider with documentation
  • Receives a vaccine dose which is self-reported with or without documentation
  • Does not receive a vaccine dose offered by the reporting facility

Please note: If your facility batch submits data or uses Health Information Exchange (HIE)/Electronic Data Interchange (EDI) data submission methods, please follow the guidance provided by your organization.

*Date is subject to change.

Figure 1: Vaccination Reporting Module

Figure 1: Vaccination Reporting Module

For more information about the new EQRS reporting process for vaccinations, please refer to the EQRS Vaccination Data Submission Requirements and Frequently Asked Questions resource that is available on the Education page on www.MyCROWNWeb.org. Additionally, the Vaccination Module will be presented during the September 8, 2022, EQRS Town Hall event. Register for the September 8, 2022, EQRS Town Hall event here.

Admission in Support of Transplant:

On July 14, 2022, CMS added the Admission in Support of Transplant feature on the Manage Patient screen under the Admissions tab in the Admission Information section in EQRS. This feature includes two new discharge reasons and an updated description of an existing discharge reason. The two new discharge reasons are Delayed Function Resolved following a Transplant and Delayed Function Unresolved following a Transplant. Additionally, the updated description of the existing discharge reason has been changed from Recovered Function to Recovered Function of Original Kidney.

Figure 2: Admission in Support of Transplant Feature: New Discharge Reasons

Figure 2: Admission in Support of Transplant Feature: New Discharge Reasons

The Dialysis in Support of Transplant feature allows EQRS to retain two open admissions on a single patient and is intended for patients that require temporary dialysis after receiving a kidney transplant. Facilities may initiate a second admission in EQRS (while the patient is currently admitted to a transplant facility) if the Admit Reason is Dialysis in Support of Transplant. The Discharge Reason of Delayed Function Resolved following a Transplant or Delayed Function Unresolved following a Transplant should be used when the Admit Reason is Dialysis in Support of Transplant (displayed in Figure 2 above) and the patient has either gained function of their transplanted kidney and no longer needs dialysis or the patient’s transplanted kidney has failed.

Please note: If your facility batch submits data or uses HIE/EDI data submission methods, please follow the guidance provided by your organization.

Parathyroid Hormone Reporting Fields:

On July 28, 2022, CMS added new parathyroid hormone (PTH) reporting fields to the Manage Clinical screen, under the Mineral Metabolism section in EQRS. The new PTH reporting fields include Parathyroid Hormone Value and date (Month, Day, Year), Parathyroid Hormone Method, and Parathyroid Hormone Upper Limit Assay Range (displayed in Figure 3 below). Dialysis facilities can report PTH values monthly and must select N/A if a PTH value was not measured for the patient for the clinical month. The Parathyroid Hormone Method, Parathyroid Upper Limit Assay Range and date fields are required fields when a PTH value is entered. Reporting of PTH data allows CMS to assess bone mineral management and adverse outcomes associated with the management of PTH among the ESRD patient population.

Please note: If your facility batch submits data or uses HIE/EDI data submission methods, please follow the guidance provided by your organization.

Figure 3: PTH Reporting Fields (located on the Manage Clinical screen, under Mineral Metabolism)

PTH Reporting Fields listed.

 


From the Chat Box

Question: CMS requires that all ESRD patients are admitted in EQRS within 5 business days of the patient starting dialysis at the facility. How can I confirm that all current patients at my facility are admitted to my facility in EQRS?

Answer: There are reports available within EQRS that can help determine if any patients are missing from the facility census in EQRS. These include the Patient Events Report and Patient Roster Report. The Patient Events Report and Patient Roster Report should be generated monthly to identify any discrepancies between the facility’s internal census and the census in EQRS. In addition to using these reports to confirm patient admission and census information, facilities can also use these reports to confirm that patient discharge and treatment information is correctly listed in EQRS. Monitoring this information helps to ensure that permanent patients are correctly documented in EQRS and that the CMS-2744 Annual Facility Survey data are accurate. It also allows for the timely submission of various CMS forms, as well as EQRS Clinical Data.

Please note: Facilities that batch submit data into EQRS need to consult their organization on how to resolve missing admissions and/or data in EQRS, prior to manually correcting the data in EQRS.

The Patient Events Report contains patient admission and discharge information for a specific date range and can be used to ensure all patient admissions and discharges are accounted for in EQRS. The Patient Roster Report contains patient census, patient treatment and admission information for a specific date and can be used to ensure patient admission and treatment information is correct in EQRS. To generate a Patient Events Report and/or a Patient Roster Report, login to EQRS, click on the Reports tab, and then select the desired report (see Figure 4 below).

Figure 4: EQRS Reports (Patient Events Report and Patient Roster Report)

Reports screen of EQRS, with Patient Events Report and Patient Roster Report highlighted by a red box

Facilities can contact their ESRD Network for further guidance and/or assistance with resolving patient admission issues. Use this link to find your ESRD Network’s contact information: https://esrdncc.org/en/ESRD-network-map/.

For additional information on EQRS activities and CMS timelines for these activities, refer to the EQRS Data Management Guidelines: https://mycrownweb.org/?smd_process_download=1&download_id=6011


How to Route Questions

Please do NOT include patients’ Protected Health Information (PHI) and Personally Identifiable Information (PII) (such as patient name, date of birth, social security number, Medicare Beneficiary Identifier, and Health Insurance Claim Number) when submitting a ticket and/or inquiry to the QualityNet Q&A Tool, CCSQ Service Center or 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 contacting the QualityNet Q&A Tool, CCSQ Service Center or ESRD Network.

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 submitted CMS-2728 (version 2014 or older), 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
  • Making modifications on submitted CMS-2728 (version 2018 or newer) or CMS-2746 Forms
  • Quality Improvement Activities (QIAs)
  • Patient grievances and/or facility concerns
ESRD Network Directory:

Contact your ESRD network directly. Use the link below if you need assistance finding your ESRD Network’s contact information.

https://esrdncc.org/en/ESRD-network-map/

 


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.

2022 EQRS Data Submission Schedule for:
EQRS Clinical Data
Reporting Month Data Submission Deadline
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

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