August 2023 EQRS News
In This Issue:
PY 2024 ESRD QIP Preview Period
CY 2024 ESRD PPS Proposed Rule
Register for the EOCT Town Hall
How to Navigate the ESRD QIP UI in EQRS
EQRS Data Submission Deadlines
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Upcoming Events:
New User Training
- August 18, 2023 • 2:00-3:30 PM ET
Web Resources:
Conditions for Coverage for ESRD Facilities
PY 2024 ESRD QIP Preview Period
The Payment Year (PY) 2024 End Stage Renal Disease Quality Incentive Program (ESRD QIP) Preview Period opened on July 17, 2023, and will remain open for approximately 30 days, closing on August 17, 2023. During the PY 2024 ESRD QIP Preview Period, the Centers for Medicare & Medicaid Services (CMS) recommends the following activities:
- Facility Viewers and Facility and Corporate Points of Contact (POCs) should review scores and reports via the ESRD QIP user interface (UI) in the ESRD Quality Reporting System (EQRS)
- Facility and Corporate POCs should use the ESRD QIP UI in EQRS to submit any inquiries regarding PY 2024 scores before the preview period concludes
Reports in the ESRD QIP UI in EQRS are accessible based on EQRS user role and availability. Reports include the Performance Score Report (PSR) and the Patient List Report (PLR), as well as the Performance Score Summary Report (PSSR) for Corporate POCs.
Additional information on the PY 2024 ESRD QIP Preview Period is available on the QualityNet website, including the PY 2024 Guide to the ESRD QIP PSRs, and the PY 2024 ESRD QIP UI Quick Start Guide. Go to the QualityNet website to download these materials by clicking on “Reports” or “Resources”. More information on the ESRD QIP preview period activities and how to access your ESRD QIP preview period reports and scores will be presented on the August 8, 2023, ESRD Outreach, Communication and Training (EOCT) Town Hall event. Register for the August EOCT Town Hall event here.
CY 2024 ESRD PPS Proposed Rule
On June 30, 2023, the Calendar Year (CY) 2024 ESRD Prospective Payment System (PPS) Proposed Rule was published on the Federal Register website. Each year CMS issues a proposed rule to update Medicare payment policies and rates under the PPS. This rule proposes updates to the ESRD QIP requirements and policies that reflect CMS’s commitment to achieving equity in healthcare.
CMS requests public comments on the proposed rule. To submit a comment, follow the instructions in the proposed rule that is published on the Federal Register website. Comments must be submitted by the closure of the comment period on August 25, 2023, at 11:59 p.m. Eastern Time (ET).
For more information, click on the following links:
Additional information on the CY 2024 ESRD PPS Proposed Rule will be presented on the August 10, 2023, proposed rule webinar. Register for the proposed rule webinar here.
Register for the EOCT Town Hall
Join the ESRD Outreach, Communication and Training (EOCT) Team for a Town Hall event containing information on various ESRD reporting activities, ESRD QIP UI training, and PY 2024 ESRD QIP Preview Period information and activities.
Date: August 8, 2023
Time: 2:00 p.m. – 3:30 p.m. ET
The following topics will be discussed:
- ESRD Data Submission Deadlines and EOCT Announcements
- ESRD QIP UI Training
- PY 2024 ESRD QIP Preview Period Reports and Activities
How to Navigate the ESRD QIP UI in EQRS
EQRS users must use EQRS to access the ESRD QIP UI (Figure 1). Refer to the PY 2024 ESRD QIP UI Quick Start Guide for assistance in navigating and/or obtaining access to the QIP application within EQRS. The ESRD QIP application allows Facility Viewers and Facility and Corporate Points of Contact (POCs) to perform the following tasks within the application:
- View ESRD QIP performance scores and feedback
- Submit, save, and reply to preview period inquiries (Facility/Corporate POCs only)
- View previously submitted preview period inquires
- View and download preview period reports
Access the ESRD QIP application though the EQRS login page at https://eqrs.cms.gov/globalapp/. Reports in the ESRD QIP UI in EQRS are accessible based on EQRS user role and availability.
Figure 1: Navigating to the ESRD QIP UI in EQRS
Additional information on navigating the ESRD QIP UI in EQRS will be presented on the August 8, 2023, EOCT Town Hall event. Register for the August EOCT Town Hall event here.
From the Chat Box
Question: My facility has past due CMS-2728 Forms for patients that are no longer admitted to my facility. How can I get these forms off my Dashboard in EQRS?
Answer: The CMS-2728 Form will no longer display on the facility’s dashboard in EQRS once the facility has submitted the form in EQRS. The facility is required to complete a CMS-2728 Form for all ESRD patients even if the patient is no longer receiving treatment at the facility.
Enter all required information for the CMS-2728 Form in EQRS. Save and print the form to have the nephrologist and patient sign it. Have the nephrologist and patient review and sign the form, then enter their signature dates in EQRS and submit the form in EQRS. The facility can also contact the patient’s current dialysis facility for assistance in obtaining the patient’s signature on the CMS-2728 Form, if needed.
If the patient is unable to sign the form, it should be signed by a relative, a person assuming responsibility for the patient or by a survivor. If you are still unable to obtain a signature and the patient has passed away, the form can be submitted without a signature. Make sure that the patient’s date of death has been entered in EQRS and submit the CMS-2728 Form with a blank patient signature date field. EQRS will recognize that the patient is deceased and will accept the form in the system.
Note: Prior to submitting a CMS-2728 Form in EQRS, review the information in the form with the patient and nephrologist for accuracy and have them sign the form. The facility can then submit the form in EQRS. A form should not be submitted prior to obtaining all required signatures. A patient signature on the CMS-2728 Form is not required if the patient has passed away.
Question: I am getting an error message that says Duplicate Patient or Near Match Patient when trying to admit my patient in EQRS. How can I resolve the error message and admit my patient in the system?
Answer: Review the patient’s information in EQRS for accuracy. Correct any identified errors and/or typos and try to admit the patient in EQRS again. For billing purposes, be sure to enter the patient’s Medicare Beneficiary Identifier (MBI), if the patient is currently or has previously received Medicare benefits. If the information entered in EQRS is correct and you are still unable to admit the patient in EQRS, or the patient does not have a Social Security Number (SSN), please contact your ESRD Network for assistance.
Use this link to find your ESRD Network contact information: https://esrdncc.org/en/ESRD-network-map/.
Note: If your facility batch submits data or uses a Health Information Exchange/Electronic Data Interchange method for data submission, please follow the guidance provided by your organization.
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:
|
QualityNet Question & Answer (Q&A) Tool: https://cmsqualitysupport. Note: Access EQRS training and/or educational materials on the Education page on MyCROWNWeb.org. |
EQRS System-related Questions or Issues:
|
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:
|
ESRD Network Directory:
Contact your ESRD Network directly. Use the link below if you need assistance finding your ESRD Network’s contact information. |
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 |
| 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.