March 2022 EQRS News

The Centers for Medicare & Medicaid Services (CMS) extended the End Stage Renal Disease (ESRD) Quality Reporting System (EQRS) data submission deadline for all 2021 data. The data submission deadline for the January 2021-December 2021, reporting months was extended to March 31, 2022, at 11:59 p.m. Pacific Time (PT). This data submission deadline applies to:

EQRS Clinical Data
Clinical Depression Screening and Follow Up
In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Attestations

Additionally, CMS has extended the EQRS Clinical Data submission deadline for January 2022-February 2022, to May 31, 2022 at 11:59 p.m. PT.

Beginning March 2022, clinical months will resume for data submission on the first of the month and close approximately two months after the end of the reporting month.

CMS-2744 ESRD Annual Facility Survey

At the start of each calendar year, CMS requires that all Medicare-certified dialysis and transplant facilities complete the CMS-2744 survey in 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 coverage, vocational rehabilitation, and facility staff counts.

Facility representatives begin the CMS-2744 survey completion process in EQRS by generating a CMS-2744 survey in EQRS. Facilities must review the survey for accuracy and correct any identified errors. To assist facilities with verifying that the survey data are correct, CMS added four new downloadable dialysis reports and one new downloadable transplant report to the View Facility Form 2744 screen in EQRS. Facilities should review these reports to identify any errors and make corrections, accordingly. Once all needed corrections have been made to the patient record(s), the facility must regenerate the survey to update the data on the survey. After a facility submits the survey to their local ESRD Network for review, they must monitor their forms’ status in EQRS and work with their ESRD Network to finalize the forms.

Please note: Facilities need to follow guidance provided by their ESRD Network and organization, prior to initiating the CMS-2744 survey, as some organizations may have their surveys completed 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/.

For additional information on how to complete the CMS-2744 survey, refer to the 2021 CMS-2744 Training Aid that is available from www.MyCROWNWeb.org.

ESRD QIP Final PY 2022 PSRs & PSCs Now Available

As of February 18, 2022, Payment Year (PY) 2022 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, the PSCs should be posted in English and Spanish no later than Friday, March 11, 2022 (15 days from their release date). PY 2022 PSCs must remain posted through December 31, 2022.

Per the calendar year (CY) 2022 ESRD 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 EQRS using the ESRD QIP UI for up to two years after the current PY. 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 Guide to PY 2022 ESRD QIP PSR document.

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.

From the Chat Box

Question: How can I verify my CMS-2744 survey data, so that I can make any necessary corrections, if needed?

Answer: EQRS contains various reports that will assist with verifying your survey data. These reports are available on the View Facility Form 2744 screen and are indicated by a down arrow in the blue sections within the survey, as displayed in the example screenshot below. To view and download a survey report, click on the report link(s) in the blue sections on the View Facility Form 2744 screen. After reviewing the reports and identifying any errors, make any needed corrections in the patient record(s). Once corrections are made in the patient record(s), be sure to regenerate the CMS-2744 survey to update the auto-populated data and re-download the reports for review with the updated data.

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 CMS-2728 or CMS-2746 form, multiple Patient IDs, batching errors, etc.) Other technical issues with EQRS not working properly	*QualityNet Service Center Contact Information:* Hours of operation are Monday through Friday 8 a.m.-8p.m. ET and can be reached via: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/*

Note: To access EQRS training and/or educational materials visit the Education page from MyCROWNWeb.org.

EQRS Data Submission Deadline

Dialysis facilities must submit all CY 2021 data by March 31, 2022, at 11:59 PM PT 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.

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

2022 EQRS Data Submission Schedule for: EQRS Clinical Data
Reporting Months	Data Submission Deadline
January 2022	May 31, 2022 at 11:59 PM PT
February 2022	May 31, 2022 at 11:59 PM PT
March 2022*	May 31, 2022 at 11:59 PM PT

*Starting March 2022, 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.

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