March 2023 EQRS News

Each calendar year, the Centers for Medicare & Medicaid Services (CMS) requires that all Medicare-certified dialysis and transplant facilities complete the CMS-2744 survey in the End Stage Renal Disease (ESRD) Quality Reporting System (EQRS). This survey provides a final count of all patients and treatments provided by a dialysis or transplant facility during the prior calendar year. It also includes important facility and patient demographic information, such as Medicare status, vocational rehabilitation, and facility staff counts.

Facilities can begin the CMS-2744 survey completion process by generating a CMS-2744 survey in EQRS. The facility must review the survey for accuracy and correct any identified errors. To assist with verifying that the survey data are correct, facilities can download four dialysis reports and one downloadable transplant report from the View Facility Form 2744 screen in EQRS (Figure 1). Facilities should review these reports to identify any errors and make corrections. Once a facility makes corrections to the patient record(s), the facility must regenerate the survey to update the data on the survey. After the survey is submitted to their local ESRD Network for review, the facility must monitor the status of the form in EQRS and work with their ESRD Network to finalize the form.

Please note: Facilities must follow guidance provided by their ESRD Network and organization prior to initiating the CMS-2744 survey, as some organizations may complete their surveys at the corporate level. Additionally, dialysis and transplant facilities must comply with the survey deadline established by their ESRD Network. To locate your ESRD Network, use this link:
https://esrdncc.org/en/ESRD-network-map/.

Figure 1: Downloadable CMS-2744 Survey Report on the View Facility Form 2744 Screen

Figure 1: Downloadable CMS-2744 Survey Report on the View Facility Form 2744 Screen

For additional information on how to complete the CMS-2744 survey, refer to the 2022 CMS-2744 Training Aid that is available on the Education page on MyCROWNWeb.org.

ESRD QIP Final PY 2023 PSRs & PSCs Now Available

On February 10, 2023, Payment Year (PY) 2023 ESRD Quality Incentive Program (ESRD QIP) Final Performance Score Reports (PSRs) and Performance Score Certificates (PSCs) became available via the ESRD QIP user interface (UI) in EQRS. As a reminder, facilities must post the PSCs in English and Spanish no later than Monday, March 6, 2023 (15 business days from their release date). PY 2023 PSCs must remain posted through December 31, 2023.

Facilities can access final PSRs and PSCs via EQRS using the ESRD QIP UI for up to three years. For instructions on how to access the ESRD QIP UI, refer to the PY 2023 ESRD QIP UI Quick Start Guide. For additional information about the PSR, refer to the Guide to PY 2023 ESRD QIP PSR. For additional details on ESRD QIP scoring policies, please refer to the Calendar Year (CY) 2023 ESRD Prospective Payment System (PPS) Final Rule, available in the Federal Register.

For technical issues with accessing reports in the ESRD QIP UI, please contact the Center for Clinical Standards and Quality (CCSQ) Service Center Monday-Friday 8 a.m.-8 p.m. Eastern Time (ET) via phone at (866) 288-8912, email at q netsupport-esrd@cms.hhs.gov, or by going to CCSQ Support Central.

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 and the new National Healthcare Safety Network (NHSN) COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) Vaccination Reporting Measure.

Date: March 23, 2023
Time: 2:00 p.m. – 3:30 p.m. Eastern Time (ET)

The following topics will be discussed:

EQRS Data Submission Deadlines and Announcements
NHSN COVID-19 HCP Vaccination Reporting Measure
ESRD QIP PY 2023 Final PSRs and PSCs Overview
CMS-2744 Annual ESRD Facility Survey Overview
Frequently Asked Questions

From the Chat Box

Question: I am getting warning and error messages when I try to submit the CMS-2744 survey. What should I do?

Answer: If you receive a warning message, verify that the counts in the survey are accurate and enter a comment that the counts have been verified. If you receive an error message, identify the patient(s) causing the error and correct the record(s) accordingly. Next, regenerate the survey to verify that the error message has been resolved. For more information on how to address warning and error messages, refer to slides 77-84 of the 2022 CMS-2744 Training Aid.

NHSN COVID-19 HCP Vaccination Measure

Beginning in PY 2025 (CY 2023), CMS added the NHSN COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) measure to the ESRD QIP Reporting Measure Domain. The Reporting Measure Domain represents 10 percent of the Total Performance Score. The measure tracks the percentage of a facility’s healthcare workforce that has been vaccinated through data reported via the Centers for Disease Control and Prevention’s (CDC’s) NHSN web-based surveillance system. More specifically, dialysis facilities are required to report at least one self-selected week of data each month in the Weekly COVID-19 Vaccination Module (Figure 2) by the quarterly NHSN COVID-19 HCP Vaccination reporting deadlines (Table 1).
Reporting Tip: To ensure successful reporting to NHSN, facilities need to ensure that the self-selected week reported to NHSN ends in the month the facility is intending to report.

Figure 2: COVID-19 Vaccination Summary Data Fields

Table 1: 2023 NHSN COVID-19 HCP Vaccination Quarterly Reporting Deadlines

Quarter	Months Reported	Quarterly Deadline	30-day Preview Period begins	Publicly Reported
1	January-March	June 30, 2023	October 2023	January 2024
2	April-June	October 2, 2023	January 2024	April 2024
3	July-September	January 2, 2024	April 2024	July 2024
4	October-December	April 1, 2024	July 2024	October 2024

For additional details regarding the NHSN COVID-19 HCP Vaccination measure and related reporting requirements, refer to the following resources:

CY 2023 ESRD PPS Final Rule available in the Federal Register
NHSN Weekly HCP COVID-19 Vaccination landing page
ESRD QIP CY 2023 Measure Technical Specifications pages 35-36

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.

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 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.

2023 EQRS Submission Schedule for: EQRS Clinical Data
Reporting Month	Data Submission Deadline
January 2023	March 31, 2023, at 11:59 PM PT
February 2023	May 1, 2023, at 11:59 PM PT
March 2023	May 31, 2023, at 11:59 PM PT
April 2023	June 30, 2023, at 11:59 PM PT
May 2023	July 31, 2023, at 11:59 PM PT
June 2023	August 31, 2023, at 11:59 PM PT
July 2023	October 2, 2023, at 11:59 PM PT
August 2023	October 31, 2023, at 11:59 PM PT
September 2023	November 30, 2023, at 11:59 PM PT
October 2023	January 2, 2024, at 11:59 PM PT
November 2023	January 31, 2024, at 11:59 PM PT
December 2023	February 29, 2024, at 11:59 PM PT

2023 EQRS Submission Schedule for: Depression Screening and Follow Up Assessments
Assessment Period	Data Submission Deadline
January 2023 – December 2023 (All months in 2023)	February 29, 2024, at 11:59 PM PT

2023 EQRS Submission Schedule for: In-Center Hemodialysis Consumer Assessment of Healthcare Providers Systems (ICH CAHPS) Facility Attestation
Attestation Period	Submission Deadline
January 2023 – December 2023 (All months in 2023)	February 29, 2024, at 11:59 PM PT

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