On March 22, 2020 CMS announced relief from QIP-related reporting requirements for CROWNWeb and the ESRD QIP. Find the full CMS press release at https://www.cms.gov/newsroom/press-releases/cms-announces-relief-clinicians-providers-hospitals-and-facilities-participating-quality-reporting. An excerpt follows:
“CMS will not count data from January 1, 2020 through June 30, 2020 (Q1-Q2) for performance or payment programs. Data does not need to be submitted to CMS for this time period… No data reflecting services provided January 1, 2020 through June 30, 2020 will be used in CMS’s calculations for the Medicare quality reporting… programs. This is being done to reduce the data collection and reporting burden on providers responding to the COVID-19 pandemic.”
CMS published an additional bulletin on March 27, https://www.cms.gov/files/document/guidance-memo-exceptions-and-extensions-quality-reporting-and-value-based-purchasing-programs.pdf, with ESRD information on pp.9-10. This bulletin clarifies the original and includes new information on NHSN QIP relief, and information on opting out of the relief:
“Dialysis facilities should be aware of the potential subsequent impact to a facility’s total performance score (TPS) when data are excluded from score calculations. Facilities impacted by COVID-19 may elect to opt out of the CMS granted exception by emailing the request to the ESRD QIP at email@example.com. The email must be sent by the dialysis facility’s chief executive officer (CEO) or designee. We are requesting that a dialysis facility make this request within 90 days of March 22, 2020. For further assistance regarding the ESRD QIP information contained in this message, please contact the ESRD QIP at firstname.lastname@example.org.”
PSSRs: CMS has announced that PY2019 Performance Score Summary Reports or PSSRs are now available. The PSSR is a spreadsheet containing the performance values of each facility for PY2019. It provides information about facility performance on each ESRD QIP measure as well as the Total Performance Score. Find the PSSRs at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/Downloads/PY2019-Performance-Score-Summary-Report-.XLSX. It’s a 12+ megabyte file, so it may take several minutes to download and open.
NHSN: CMS has also announced an extension to the NHSN data entry deadline for the ESRD QIP fourth reporting quarter of 2018 (data for October 1 – December 31, 2018) from March 31, 2019 to April 1, 2019.
Assistance regarding PSSRs or the NHSN deadline can be obtained by contacting the ESRD QIP Support Team using the ESRD QIP Q&A Tool at https://cms-ocsq.custhelp.com/app/homeesrdqip/p/960. For questions or concerns regarding use of the ESRD QIP system, contact the QualityNet Help Desk at email@example.com or 866-288-8912 between 5am and 7pm PT Monday-Friday.
Pain Assessment data submission into CROWNWeb will no longer be required by CMS starting March 1, 2019. The Pain Assessment screen will remain active for facilities to review previously reported data. For details see http://mycrownweb.org/2019/02/pain-assessment-submission/.
CMS has discovered that the data file used to calculate PY2019 ESRD QIP Performance Scores omitted data on PD patients, which resulted in inaccurate Mineral Metabolism, Hypercalcemia, and Total Performance Scores for about one-third of eligible facilities. A complete list of impacted facilities can be found at https://www.qualitynet.org/dcs/BlobServer?blobkey=id&blobnocache=true&blobwhere=1228890843976&blobheader=multipart%2Foctet-stream&blobheadername1=Content-Disposition&blobheadervalue1=attachment%3Bfilename%3DESRD_QIP_PY19_AffctdDlysFclts.pdf&blobcol=urldata&blobtable=MungoBlobs.
CMS has recalculated PY2019 Performance Score results. Corrected PSRs and Patient List Reports will be released on or before August 24, 2018. While only impacted facilities will see a change in their reports, all facilities will receive new reports. In order to provide facilities with sufficient time to review their revised reports, CMS has extended the QIP Preview Period till September 19, 2018 at 11:59 PM PDT. Try to submit your Clarification Questions by early September, so CMS has time to respond and you have time before the deadline to submit your Formal Inquiry, if necessary.
For further assistance regarding the QIP Preview, please contact the ESRD QIP Support Team using the ESRD QIP Q&A Tool at https://cms-ocsq.custhelp.com/app/homeesrdqip/p/960. If you have questions or concerns regarding use of the ESRD QIP system, please contact the QualityNet Help Desk at firstname.lastname@example.org or 866-288-8912 between 5 am and 5 pm PDT Monday through Friday.
CMS has announced that the RELI Group will be conducting a data validity and reliability study on CROWNWeb and NHSN data. They have randomly selected 335 facilities nationwide and sent a certified letter to each selected facility (or their LDO) in February with instructions on how to participate. Facilities that are selected but do not respond will have their QIP TPS reduced by ten points. For details see https://s3-us-west-2.amazonaws.com/nwrn.org/files/CMS/DVR.Memo.0118.pdf.