January 2022 EQRS News

End Stage Renal Disease (ESRD) facilities are reminded to submit January-December 2021, quality reporting data to the ESRD Quality Reporting System (EQRS) by February 28, 2022 at 11:59 PM Pacific Time (PT). This data submission deadline applies to:

EQRS Clinical Data
Clinical Depression Screening and Follow-up reporting
Calendar Year (CY) 2021 In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) facility attestations

Final PSRs & PSCs for PY 2022 Update

Payment Year (PY) 2022 ESRD Quality Incentive Program (QIP) Final Performance Score Reports (PSRs) and Performance Score Certificates (PSCs) will be available for download in February 2022. As a reminder, PSCs must be posted in both English and Spanish within 15 days of their availability and must remain posted until December 31, 2022.Payment Year (PY) 2022 ESRD Quality Incentive Program (QIP) Final Performance Score Reports (PSRs) and Performance Score Certificates (PSCs) will be available for download in February 2022. As a reminder, PSCs must be posted in both English and Spanish within 15 days of their availability and must remain posted until December 31, 2022.

Per the CY 2022 ESRD QIP Prospective Payment System (PPS) final rule, all PY 2022 PSCs will display “N/A” or “Not Applicable” in place of a Total Performance Score (TPS). For additional details, please refer to the CY 2022 ESRD PPS final rule, available on the Federal Register.

The final PSR and PSC can be accessed via the ESRD QIP user interface (UI) in EQRS. For instructions on how to access the ESRD QIP UI, refer to the PY 2022 ESRD QIP UI Quick Start Guide. For additional information about the PSR, refer to the PY 2022 Guide to the ESRD QIP Performance Score Report document. Both resources are available for download from the QualityNet website: https://qualitynet.cms.gov/esrd/esrdqip.

For technical issues with accessing reports in the ESRD QIP UI, please contact the QualityNet Service Center Monday-Friday 8 a.m.-8 p.m. Eastern Time (ET) via phone at: (866) 288-8912 or via email at: qnetsupport-esrd@hcqis.org.

How to Route Questions

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 Q&A Tool:

https://cmsqualitysupport.
servicenowservices.com/qnet_qa

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 2728 or 2746 forms, multiple Patient IDs, batching errors, etc.)
Other technical issues with EQRS not working properly

QualityNet Service Center:

Hours of operation:
Monday-Friday 8 a.m.-8p.m. ET
Phone: (866) 288-8912
Email: qnetsupport-esrd@hcqis.org

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/

New Features in EQRS

Nursing Home Identifier:

A nursing home identifier feature has been added to EQRS to track patients that are residing in a nursing home.

This new feature is in the Contact Information section of the View Patient Demographics screen under the Patient tab, and includes a checkbox that reads “Is the patient in a nursing home setting?” If a patient resides in a nursing home and/or the patient’s nursing home status changes at any point during the month, EQRS users must update the nursing home setting information. To report a Nursing Home Setting, select one of the three reporting options from the Nursing Home Setting drop-down menu: Permanent Resident, Short Term Care or Rehabilitation or Other. Nursing home information does not need to be entered into EQRS if the patient does not reside in a nursing home.

Patient demographic information, including the patient’s nursing home status should be reviewed monthly, at a minimum, and/or updated at any point during the month when there is a change to this information.

Telemedicine Usage:

A feature for telemedicine usage has been added to EQRS to track patients that are using telemedicine to receive dialysis-related care.

This new feature has been added as a new reporting section on the Manage Clinical screen in EQRS, and it applies to both Hemodialysis and Peritoneal Dialysis Collection Types. If a patient received any telemedicine visits during the reporting month, enter the date of the last visit and total number of visits during the month. Dialysis facilities will need to determine the best way for their facility to track, monitor, and report this information.
Telemedicine reporting should be completed every clinical month on each patient. For additional information about the telemedicine feature in EQRS, refer to the Telemedicine Usage FAQs document available on the Education page on MyCROWNWeb.org.

Important note: If your facility batch submits or uses a Health Information Exchange (HIE)/Electronic Data Interchange (EDI) method, follow the guidance provided by your organization. If batch or HIE/EDI submission is unavailable, the facility will be responsible for reporting the nursing home setting information and telemedicine usage data into the EQRS UI until batch or HIE submission is available. For additional information on these new EQRS features, refer to the November Town Hall event materials available on the Events page on MyCROWNWeb.org.

From the Chat Box

Question: Do facilities have to post their PY 2022 PSC even if there will be no TPS awarded and no payment penalty?

Answer: Yes. Although the PY 2022 PSCs will display “N/A” or “Not Applicable,” and no TPSs will be awarded or calculated, facilities must still download, print, and post both English and Spanish versions of the PSC in a prominent location of their facility. The certificates must be posted within the first 15 business days of their availability and remain posted throughout the duration of 2022. If you have additional ESRD QIP related questions, please submit your questions through the QualityNet Question & Answer (Q&A) Tool.

If you are having technical issues with accessing the PSC in the ESRD QIP UI, please contact the QualityNet Service Center. The QualityNet Service Center is open Monday-Friday 8 a.m. to 8 p.m. ET and can be reached via phone at: (866) 288-8912 or via email at: qnetsupport-esrd@hcqis.org.

EQRS Data Submission Deadline

Dialysis facilities must submit all CY 2021 data by February 28, 2022, at 11:59 PM PT to meet CMS reporting requirements. 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 2021 data will support the PY 2023 ESRD QIP. For additional details, please refer to the CY 2022 ESRD PPS final rule, available from the Federal Register.

2021 EQRS Data Submission Schedule for:

EQRS Clinical Data
Clinical Depression Screening
ICH CAHPS Facility Attestation*

Reporting Months

Data Submission Deadline

January 2021 – December 2021
(All months in 2021)

February 28, 2022 at 11:59 PM PT

*CY 2021 ICH CAHPS Attestation will open for submission in EQRS on January 1, 2022.

Dialysis facilities can begin submitting January 2022 data in EQRS as of January 1, 2022. As a reminder, each month will open for data submission on the first of the month and will close approximately two months after the end of the reporting month.

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.

2022 EQRS Data Submission Schedule for: EQRS Clinical Data Clinical Depression Screening ICH CAHPS Facility Attestation*
Reporting Months	Data Submission Deadline
January 2022	March 31, 2022 at 11:59 PM PT
February 2022	May 2, 2022 at 11:59 PM PT
March 2022	May 31, 2022 at 11:59 PM PT

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