December 2023 EQRS News
In This Issue:
CY 2024 ESRD ESRD PPS Final Rule
Participate in EQRS User Feedback
Register for the EOCT Town Hall
ESRD QIP PY 2024 Final PSRs & PSCs Now Available
Facility Commitment to Health Equity Measure
ESRD Data Submission Deadlines
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Upcoming Events:
New User Training
- December 12, 2023 • 2:00-3:30 PM ET
Web Resources:
Conditions for Coverage for ESRD Facilities
CY 2024 ESRD PPS Final Rule
On November 6, 2023, the Centers for Medicare & Medicaid Services (CMS) published the Calendar Year (CY) 2024 End Stage Renal Disease (ESRD) Prospective Payment System (PPS) Final Rule in the Federal Register. Each year CMS issues a final rule to update Medicare payment policies and rates under the PPS. This rule updates the ESRD Quality Incentive Program (QIP) requirements and includes policies to add three new measures that reflect the agency’s commitment to achieving health equity.
For additional details on the CY 2024 ESRD PPS Final Rule, register for the final rule webinar on January 11, 2024. Use these links for additional rule information:
Participate in EQRS User Feedback
The CMS ESRD Quality Reporting System (EQRS) Program invites you to participate in upcoming User Research studies with the Human Centered Design (HCD) team. Our HCD team works with users to help improve the overall experience of the EQRS website/user interface (UI). With your feedback, we strive to design the right solution and improve the overall user experience. If you are interested in providing input for research studies or have feedback, please contact us at eqrsuserresearch@cms.hhs.gov.
Register for the EOCT Town Hall
Join the ESRD Outreach, Communication, and Training (EOCT) Team for a Town Hall event on ESRD reporting activities, various ESRD QIP information, and EQRS updates, including recently added features and enhancements.
Date: December 14, 2023
Time: 2:00 p.m. – 3:30 p.m. ET
Presenter will discuss the following topics:
- ESRD Data Submission Deadlines
- EQRS Updates including the new Dashboard Reports feature, and the new Facility Attestations screen
- CY 2024 ESRD PPS Final Rule Recap
- Facility Commitment to Health Equity measure (new measure in Payment Year (PY) 2026)
- PY 2024 ESRD QIP final PSRs and PSCs
ESRD QIP PY 2024 Final PSRs & PSCs Now Available
On November 13, 2023, PY 2024 ESRD QIP final Performance Score Reports (PSRs) and Performance Score Certificates (PSCs) became available via the ESRD QIP UI in EQRS. As a reminder, facilities are required to display the English and Spanish versions of their PSC in a prominent patient area within the facility no later than Monday, December 4, 2023 (15 business days from their release date). PY 2024 ESRD QIP PSCs must remain posted throughout 2024, until next year’s PSCs are available.
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 2024 ESRD QIP UI Quick Start Guide. For additional information about the PSR, refer to the PY 2024 Guide to the ESRD QIP PSR. For additional details on the PY 2024 ESRD QIP scoring policies, please refer to the CY 2022, 2023, and 2024 ESRD PPS Final Rules available online at the Federal Register.
For additional information on the ESRD QIP final PSRs and PSCs and how to access them, register for the upcoming December 14, 2023, EOCT Town Hall event.
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 via phone at 866-288-8912, email at qnetsupport-esrd@cms.hhs.gov, or by going to CCSQ Support Central.
From the Chat Box
Question: I heard that CMS is adding reports in EQRS. How can I find the reports and what reports are currently available to facilities?
Answer: On September 5, 2023, CMS added a Dashboard Reports feature. Users can access this feature by clicking Reports Dashboards from the Reports drop-down tab in EQRS (Figure 1). Currently, EQRS users can access two dashboards to generate various reports in the Reports screen:
- Facility Hemodialysis (HD) Clinical Dashboard
- Facility Peritoneal Dialysis (PD) Clinical Dashboard
The Facility Clinical Dashboards contain three reports: The Patient Detail report, the Facility Aggregate report, and the Averages report. These reports reflect EQRS Clinical Data submitted by the facility and display several laboratory and medication values including hemoglobin, serum albumin, Kt/V, uncorrected calcium, administered erythropoiesis stimulating agents (ESAs), intravenous (IV) iron, and more. Users can filter report data for a specific patient by entering an EQRS Unique Patient Identifier in the EQRS UPI field within the dashboard. Additionally, report data displays values based on the Clinical Period Start Date and Clinical Period End Date entered in the dashboard.
Dashboard generated reports can be downloaded via the export to CSV or Excel function within the reports. Please note, the export to CSV is the preferred download method. Also, dashboard content is specific to the user’s access and role in EQRS. CMS will continue to add new dashboards to the Reports screen in EQRS. The ESRD community will continue to receive notifications via email about new dashboard releases in EQRS.
Figure 1: Accessing Dashboard Reports in EQRS
Facility Commitment to Health Equity Measure
The CY 2024 ESRD PPS Final Rule finalized a policy to add a new Facility Commitment to Health Equity measure to the ESRD QIP measure set beginning with PY 2026. This new measure will assess facility commitment to health equity using equity-focused competencies aimed at achieving health equity for:
- Racial and ethnic minority groups
- People with disabilities
- Members of the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community
- Individuals with limited English proficiency
- Rural populations
- Religious minorities
- People living near or below poverty level
Beginning CY 2024, facilities will be required to submit data annually via an attestation submission in EQRS for the Facility Commitment to Health Equity measure. Additionally, facilities will be required to attest to five domains, each representing a competency aimed at achieving health equity. Each domain is worth two points, with a total of 10 possible points. To receive a full ten points for this measure, facilities must complete and attest to engaging in all activities in each domain.
The Facility Commitment to Health Equity measure is composed of the following five domains:
- Equity is a strategic priority
- Data Collection
- Data Analysis
- Quality Improvement
- Leadership
On January 1, 2024, facilities can begin to submit, view, and edit their CY 2024 Commitment to Health Equity attestation data, and have until February 28, 2025, at 11:59 p.m. PT to complete attestation data submission in EQRS. Additionally, the Commitment to Health Equity attestation submission period will open in EQRS each year on January 1st, will remain open for the entire calendar year, and will close at the end of the EQRS December reporting deadline (approximately two months after December). Please note that if the last day of the month falls on a Saturday, Sunday, or federal holiday, the deadline will occur on the next federal business day. Users can submit the Commitment to Health Equity attestation on the Facility Attestations screen in EQRS.
Users can access the Facility Attestations screen starting on January 1, 2024, by clicking Attestation from the Facilities drop-down tab in EQRS (Figure 2). Once on the Facility Attestations screen, users can click the Commitment to Health Equity box and then click the Assessment Period for which they are reporting to start an attestation (Figure 3). Users can view, edit, and delete attestation data in EQRS until the attestation submission deadline.
Figure 2: Accessing Facility Attestations Screen in EQRS
Figure 3: Start a Commitment to Health Equity Attestation in EQRS
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 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:
|
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. |
ESRD Data Submission Deadlines
Dialysis facilities must submit their data by the established deadlines below. Not submitting the required data by these deadlines puts your facility at risk for an ESRD QIP payment reduction. Please note that if the last day of the month falls on a Saturday, Sunday, or federal holiday, the deadline will occur on the next federal business day. The data submission deadlines apply 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 |
| October 2023 | January 2, 2024, at 11:59 p.m. PT |
| November 2023 | January 31, 2024, at 11:59 p.m. PT |
| December 2023 | February 29, 2024, at 11:59 p.m. 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 |
| 2023 NHSN Submission Schedule for: ESRD Data (Dialysis Events, Bloodstream Infection (BSI) in Hemodialysis Patients, COVID-19 Vaccination Among Healthcare Personnel (HCP)) |
||
| Quarter | 2023 Reporting Months | Data Submission Deadline |
| 3 | July-September | January 2, 2024, at 11:59 PM PT |
| 4 | October-December | April 1, 2024, at 11:59 PM PT |
The information included as part of this newsletter is current as of the date of release.