CMS will host a 15 January, 2019 national call on the CY2019 ESRD PPS final rule and PY2021-22 QIP. Topics include legislative framework; updates to QIP measures, domain structure, and weights; and changes to NHSN data requirements and Validation Study. For details see https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2018-12-20-eNews.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending#_Toc532966944.
NHSN has advised that in order to be applied to your PY2020 QIP scores, your NHSN data for July 1-September 30, 2018 must be submitted and corrected by December 31, 2018. NHSN recommends:
- Review the NHSN Dialysis Event Protocol at https://www.cdc.gov/nhsn/PDFs/pscManual/8pscDialysisEventcurrent.pdf to ensure all data were correctly reported to NHSN.
- Use 3 Steps to Review Dialysis Event Surveillance Data at https://www.cdc.gov/nhsn/pdfs/dialysis/3-steps-to-review-de-data-2014.pdf.
- Use the How to Create and Read an NHSN Report for CMS ESRD QIP guide at https://www.cdc.gov/nhsn/PDFs/dialysis/CMS-QIP-NHSN-report.pdf to verify your facility has met the minimum CMS reporting requirements.
- Refer to the How to Create and Read an NHSN Report for Bloodstream Infections guide at https://www.cdc.gov/nhsn/PDFs/dialysis/BSI-cheatsheet.pdf to review your facility’s bloodstream infection rates.
Contact the NHSN Helpdesk at firstname.lastname@example.org with subject line “Dialysis” if you have any questions.
The NHSN software was updated to Version 9.2 on December 8, 2018, with many additions and changes, including analysis updates. Please carefully review pages 1 and 7-8 of the Version 9.2 release notes at https://s3-us-west-2.amazonaws.com/nwrn.org/files/NHSN/NHSN9.2.pdf for important details about these changes. To use any of the new analysis output options you must first Regenerate Datasets. Send any questions to the NHSN Helpdesk at NHSN@cdc.gov.
NHSN will present four ESRD Component trainings during November 2018. Listen-only audio for these will be available through your computer’s speakers. If you need audio via telephone, the dial-in number for all sessions is 303-248-0285 (toll), with access code 6393927.
- Introduction to the NHSN Dialysis Event Surveillance Protocol will be held on November 6, 2018 and repeated on November 7, to provide details necessary to meet the ESRD QIP requirements for NHSN reporting and BSI monitoring. Registration is required at:
The September 30, 2018 deadline for entering or editing NHSN data for QIP credit has been extended to October 1, 2018.
CMS has released the proposed ESRD QIP Technical Specifications for PY2021, 2022, and 2024. Proposed changes include:
- Elimination of Pain Assessment (NOT Depression Screening as indicated earlier), NHSN Healthcare Personnel Vaccination, Anemia Management, and Serum Phosphorous in PY2021.
- New measures for Medication Reconciliation Reporting and Existing-Patient Transplant Waitlist for PY2022.
- A new measure for Incident-Patient Transplant Waitlist in PY2024.
CMS will present an August 14, 2018 Conference Call on changes to the ESRD QIP proposed in the CY 2019 ESRD PPS Proposed Rule. For details on the Proposed Rule and comment deadline, see https://nwrnbulletins.wordpress.com/2018/07/11/cy2019-esrd-pps-proposed-rule/. Topics for the Call include:
- ESRD QIP legislative framework
- Updates to ESRD QIP measures, domain structure, and weights
- Modifications to data submission requirements
- NHSN Validation Study
- Methods for reviewing and commenting on the Proposed Rule
The target audience for the Call includes dialysis clinics and organizations, nephrologists, hospitals with dialysis units, billers/coders, quality improvement experts, and other stakeholders. The Call will not include a question and answer session.
Register for the Call at https://blh.ier.intercall.com/.
CMS has released a proposed rule for the CY2019 ESRD PPS, titled Proposed Updates to Policies and Payment Rates for the ESRD PPS, … QIP; and Payment for Renal Dialysis Services Furnished to Individuals with AKI and a fact sheet summarizing it. The ellipsis in the title refers to durable medical equipment changes included in the same proposed rule. Find the fact sheet at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-11.html.
The fact sheet includes summaries of:
- Removing the Healthcare Personnel Vaccination, Pain Assessment, Anemia Management, and Serum Phosphorus reporting measures from the PY2021 QIP.
- Restructuring domains and weights in the PY2021 QIP.
- Expanding NHSN validation in both PY2021 and PY2022.
- Adding measures for Percentage of Patients Waitlisted and Medication Reconciliation to the PY2022 QIP.
- Adding a measure on Standardized First Transplant Waitlist Ratio for Incident Patients to the PY2024 QIP.
The proposed rule can be found on the Federal Register at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14986.pdf. Comments must be received by September 10, 2018.