June 2023 EQRS News

On June 26, 2023, the Calendar Year (CY) 2024 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) Proposed Rule was displayed on the Federal Register website. Each year, the Centers for Medicare & Medicaid Services (CMS) issues a proposed rule to update Medicare payment policies and rates under the PPS. This rule proposes updates to the ESRD Quality Incentive Program (ESRD QIP) requirements. In addition, CMS is proposing policies that reflect commitment to achieving equity in healthcare. CMS requests public comment on the proposals presented in the proposed rule. To submit a public comment, follow the instructions in the proposed rule that is published on the Federal Register website.

For more information, click on the following links:

Register for the EOCT Town Hall

Join the ESRD Outreach, Communication, and Training (EOCT) Team for a Town Hall event for information on various ESRD reporting activities, new ESRD Quality Reporting System (EQRS) features including the Peritonitis Infections Module and the Transplant Dashboard for dialysis facilities, and updates to the ESRD QIP Standardized Hospitalization Ratio (SHR), Standardized Readmission Ratio (SRR), Standardized Transfusion Ratio (STrR) measures, and more.

Date: June 29, 2023
Time: 2:00 p.m. – 3:30 p.m. ET

The following topics will be discussed:

ESRD Data Submission Deadlines and EOCT Announcements
New EQRS Features: Peritonitis Infections Module and Transplant Dashboard for Dialysis Facilities
ESRD QIP SHR, SRR and STrR Measure Updates
Frequently Asked Questions

Care Compare Dialysis Data Release on Medicare.gov

In April 2023, 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) 2023 ESRD QIP public reporting files in April 2023. These reporting files contain scoring and measure performance for the ESRD QIP measures for all eligible outpatient dialysis facilities in PY 2023. The public reporting files promote data transparency and, like the star rating system, are intended to help patients make informed decisions when selecting their dialysis facility. The PY 2023 ESRD QIP public reporting files are available on the CMS.gov Provider Data Catalog website for the following ESRD QIP domain topics and quality reporting measures:

Patient & Family Engagement

In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (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 Ratio (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
Ultrafiltration Rate (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.

From the Chat Box

Question: I need to modify a form that has been submitted in EQRS. Who can help me with this?

Answer: Contact your ESRD Network for assistance with modifying a CMS-2728 or CMS-2746 Form that has been submitted in EQRS, if any of the following criteria are met:

An edit request is made within 60 days from the form’s submission date in EQRS. Please note that changes that impact patient coverage such as date of first dialysis have no time limit for making changes.
The request is coming from the facility that originally submitted the form. Only the submitting facility can request to make a change to that form.
Edits to the patient’s demographics screen and/or the admit/treatment information are completed prior to submitting a form change request to the ESRD Network
If the edit request is for a form that is version 2018 or newer:
Click this link to find your ESRD Network contact information: https://esrdncc.org/en/ESRD-network-map/.

Contact the Center for Clinical Standards and Quality (CCSQ) Service Center for assistance with modifying a CMS-2728 Form that has been submitted in EQRS, if any of the following criteria are met:

The edit request involves:
- Deleting a form that has been submitted in EQRS.
- Changing a physician name on a form that has been submitted in EQRS.
- Changing signature dates on a form that has been submitted in EQRS.
The edit request is for a form that is version 2014 or older.

The CCSQ Service Center can be reached via phone at (866) 288-8912, email at qnetsupport-esrd@cms.hhs.gov, or by going to CCSQ Support Central .

Please note: Any changes made to a previously submitted form will change the submission date in EQRS and in turn may negatively impact facility compliance of the form.

ESRD QIP SHR, SRR, and STrR Measure Updates

Beginning in PY 2024, CMS is updating the ESRD QIP technical measure specifications to express SHR and SRR clinical measure results as rates. To align with this technical update, CMS will also be converting the STrR reporting measure to a clinical measure and expressing the STrR measure as a rate beginning in PY 2025. Changing the SHR, SRR and STrR measure results from ratios to rates helps providers and patients better understand a facility’s performance on the measures and makes it easier for facilities to track their performance from year to year. Converting the STrR reporting measure to a clinical measure requires CMS to update the scoring methodology for the STrR measure so that facilities that meet previously finalized minimum data and eligibility requirements would receive a score on the STrR clinical measure based on the actual clinical values reported by the facility, rather than the completeness of the reported data. Table 1 below provides a summary of these measure changes.

Table1: ESRD QIP SHR, SRR, STrR Measure Updates

ESRD QIP Measure	Payment Year	Measure Type	Updated Measure Description
SHR	Beginning in PY 2024	Clinical	SHR is expressed as a risk-standardized rate by multiplying the facility SHR by the national average hospitalization rate.
SRR	Beginning in PY 2024	Clinical	SRR is expressed as a risk-standardized rate by multiplying the facility standardized readmission ratio by the national average readmission rate.
STrR	Beginning in PY 2025	Change from Reporting to Clinical	STrR is a ratio of the number of eligible red blood cell transfusion events observed in patients dialyzing at a facility, to the number of eligible transfusion events that would be expected under a national norm, after accounting for the patient characteristics within each facility. STrR is expressed as a risk-standardized rate by multiplying the facility STrR by the national average transfusion rate.

For additional information on the SHR, SRR and STrR measures, refer to the following resources:

CY 2023 ESRD PPS Final Rule available in the Federal Register website
ESRD QIP CY 2023 Technical Measure Specifications document

New Features in EQRS

Peritonitis Infections Module: On June 26, 2023, CMS released a Peritonitis Infections Module in EQRS. This new module captures peritonitis infection data and rates in peritoneal dialysis patients. Dialysis facilities are required to enter peritonitis infection data on the Manage Patient screen under the new Infections tab in EQRS (Figure 1). The new EQRS Peritonitis Infections Module reporting process requires dialysis facilities to document peritoneal dialysis infections when they occur. EQRS users can enter data for the following reporting sections within the module:

Patient and Event Details
Risk Factors
Lab and Diagnostic Testing
Signs and Symptoms
Outcomes

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

Figure 1: Peritonitis Infections Module

For more information about the new Peritonitis Infections Module, please refer to the CMS Infection Event Data Submission Requirements resource that is available on the Education page on www.MyCROWNWeb.org. Additionally, the Peritonitis Infections Module will be presented on the June 29, 2023, EOCT Town Hall event. Register for the June Town Hall event here.

Transplant Dashboard for Dialysis Facilities: On May 17, 2023, CMS released a Transplant Dashboard for dialysis facilities in EQRS (Figure 2). The Transplant Dashboard lists EQRS and United Network for Organ Sharing information for all living patients in a facility who are listed with one or more transplant centers and includes the contact information for those transplant centers. Dialysis facilities can access the Transplant Dashboard by clicking on the Dialysis Facility Transplant Waitlist link at the bottom of the Dashboard screen in EQRS. Additionally, facilities can view dashboard information for the purpose of:

Tracking a patient’s waitlist status
Communicating with transplant centers where their patients are listed
Helping patients maintain their active transplant status to successfully receive a kidney transplant

Figure 2: Transplant Dashboard for Dialysis Facilities

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
CMS reporting requirement questions

QualityNet Question & Answer (Q&A) Tool:

https://cmsqualitysupport.
servicenowservices.com/qnet_qa

Note: Access EQRS training and/or educational materials on the Education page on 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 can be reached Monday-Friday 8 a.m.-8p.m. ET. via:
Phone: (866) 288-8912
Email: qnetsupport-esrd@cms.hhs.gov
CCSQ Support Central:
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
- Complete a missing or saved CMS-2728 Form when the facility no longer has access to edit this screen
- Add a date of death and/or primary death code for patients who have been discharged from the 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
Conducting quality improvement activities (QIAs)
Addressing patient grievances and 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. Please note, if the last day of the month falls on a Friday, Saturday, or Sunday, or on a federal holiday, the deadline will occur on the next federal business day. Not meeting the required reporting 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
April 2023	July 3, 2023, at 11:59 PM Pacific Time (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.