Aaron Thompsonx
Adrienne Adkinsx
Adrienne Rayx

Ahmar Wazir

Anitha Chintalapati
Arnie Esparterox
Betina Fletcherx
Branon Barrettx
Carol Olsen
Cheri Jergerx
Chris Brown
Curtis Phillipsx
Deb Wilson
Dianna Christensen
Greg Eccleston
Hayley Evans
Hari Krishna Pemmasani
Heather Dubendris
Heather Moore
Howard Thomasx
Janet Lea Hutchinson
Jason Clemx
Jason Simmingtonx
Jennifer Baileyx
Justyna Sardinx
Karena S
Kathleen Prewittx
Kelly Llewellyn
Kelly Mayo
Lakshmi Erigineni
Leah Skrien
Lisa Rees
Malik Arsalan
Matt McDonoughx
Melissa Fieldhousex
Michael Kennedyx
Nathan Muzosx
Ozlem Taselx
Pandu Muddana
Porsche Dorseyx
Rachelle DuBose Caruthersx
Revathy Ramakrishnax
Sarah Fillingx
Seema Sreenivasx
Scott Laughlinx
Shalon Quinnx
Steve Goodman
Todd Johnson x
Vladimir Ladikx
Yvette Brownx
Zach Serlethx


Meeting RecordingArnie

This session will be recorded for the purpose of documenting the meeting minutes and action items. If there are any objections to the recording of this session, please make it known now. Absence of an objection to the meeting being recorded will count as consent to recording this meeting (Passcode: AqM2Mfb.) 

Feature(s) UpdateShalon/Michael

Parathyroid Hormone (PTH) and Vitamin D

  • Michael is setting up a meeting with Abby to find out what her contractor has and doesn't have
  • This information will allow Michael and team to know what fields we used to have or need to add and develop
  • They are still in the discovery phase; PI17 they are doing the exploration
  • During exploration, Michael will be inviting the EDIs and Program to the calls to determine what the EDI systems have and don't have and what can and can't be done
  • Actual system development will be in PI18; this will allow enough time to let people know what's coming
  • The deadline is a June/July timeframe
  • Questions from Nathan
    • For Vitamin D, we talked about the difference between prescribed supplements versus blood test lab values, what direction is CMS/Program thinking in going?
      • Per Michael, they are not sure at this time
      • Abby is working determining what was already collected by their contractor and what they have access too
      • If there are any differences in what was collected during CrownWeb days or even something new, Michael want's the EDI to get it as early as possible
    • Who is Abby?
      • Abby is from the Center of Medicare; a CMS division but not CCSQ specifically
      • She is one of the people that Congress is asking for this feature
      • It is a Congressional mandate not a request
      • Abby had already been working on parts of this
    • Is the July deadline to get this feature into EQRS or the deadline to actually be reporting the data?
      • Congress wants us to already be reporting it 
      • Looking at program intervals and trying to figure out which PI we can get it in
      • The July deadline is base on PI development
      • Per Nathan - to be aware that if it requires that EDIs start collecting anything new internally (something they do not already collect), they will be struggling to meet a July deadline to get their internal systems, policies and procedures, new data collection completed in 5-6 months
Identify Depressed Patients/Admission in Support of TransplantShalon/Todd

Status on questions and suggestions captured at the 11/30 PI16 System Demo

Please review for all questions: Nov 30 2021 EQRS System Demo Questions_Suggestions_01262022.docx

Recording for this discussion: 8:37 - 35:11

  • Todd Johnson oversees the ESRD network program; working with the SMEs for transplant and depression areas
  • Disclaimer: there are some portions for transplant the SME has not seen the actual module so we will have to revisit any related questions until the SME has a chance to perform a deep dive.  Also items highlight in orange are procurement sensitive information on those will be provided at a later date
  • CMS' comments can be found in the "CMS Comments" column of the table

Question #1: If the patient is screened for cognitive decline, there is a place to enter a score. No score is required for depression screening. 

  • Do we know the if the intent of the score is for cognitive decline or if it is for depression screening?
    • Per Todd, no we do not know that; will need clarification
    • Per Nathan, there was one of the fields that said to provide the score; its not clear on what the score is for
    • Suggestion to clarify in the description of that field what is the score for the cognitive decline assessment or depression screening assessment so folks know what score they're being asked for
    • Per Scott and Yvette, the score that is mentioned is for cognitive decline
    • Question from Vlad - Do we need to report both scores for depression screening and cognitive decline?
      • Per Kathleen - she does not think so, only one needs to be reported
      • Per Vlad - if you report a score for cognitive decline and not for depression screenings, what is the point of doing screenings?
    • Per Nathan - another concern is that there is not no standard assessment for cognitive decline and so just collecting a random score from different provider will mean different things
    • If the expectation is then comparing those scores across patients, you really won't be able to do that; you won't know which assessment is being used and how the scores related to each other
    •  There is a concern that as indicated in the document presented under the CMS Comment field cognitive decline should also be screening for depression is shifting the whole expectations of depression screening an adding a new screening of cognitive decline
    • The EDIs concern with this whole new Identity depresses patients is that they have not been clearly told what the expectation is besides some statistical analysis that says dialysis patients should be more depressed but the depression assessments don't show that
    • The intent of the data has never been understood so the EDIs can actually get it to achieve what CMS wants to achieve
    • Additional concerns about the level of truth of some of the questions and the ability to share of that data
    • Per Shalon, we are trying to look at the whole patient and trying to address any issues they may have and trying more accurately to capture that and screen patients and get them treatment
    • Per Nathan, depression screen assessment is not a diagnosis of depression so somebody could do the assessment today, not show as depressed b/c it's only good for a two week period
    • In addition, patients who already have a diagnosis of depression are considered an exclusion population from the assessment itself b/c they've already been diagnosed
    • Concerned that CMS/Program is comparing apples and oranges without fully understanding the two different sets of data and how they can relate to each other
    • Per Howard, their board has been discussing this and concerned about whether the personnel and the dialysis clinics are truly licensed to render a depression diagnosis
    • Per Todd, his understanding was that the social workers in the dialysis clinics would not be actually diagnosing but just leaning towards a referral
    • Per Howard, they are administering a tool but then need some guidance from the program and CMS
    • Per Rachelle Caruthers, they are not simply being asked to refer, but being asked to increase the number of patients that actually attend; that maybe outside the scope/control of the social worker in a dialysis clinic
      • In the statement of work it specifically says to increase the percent of patients who have received treatment by a mental health professional, so the statement of work is going far beyond referrals
    • Per Howard there are a lot of questions that tie into this that need to be addressed/given attention
    • Todd - How to address the issue about the diagnosis
      • Clinics that have licensed clinical social workers; they would be able to screen and make referrals
      • Social workers that are even not clinical can screen and refer depending on license level
      • We are NOT asking them to diagnose, but asking them to identify any issues the patient may have based on the screening and overall assessment of the patient
      • Per Howard we should say if the patient was offered a referral for mental health services, given the screening or the patient assessment. Trying to put down a score will open up a can of worms.  Keep the question simple. "Was the patient offered a mental health referral?"
      • Nathan agreed to Howards suggestion
    • Todd will need to talk to the SMEs around this area just discussed (action item)
    • The other piece is to be able to confirm if the patient has sought treatment or is in treatment, etc
    • Per Howard this could get into the State Law issues; could be sensitive information
    • Still need clarity on the cognitive decline score issue
      • Concern is there isn't a set of standard rules that are utilized
      • Collecting data around that isn't comparative data b/c there isn't a single tool that's utilized by the industry
      • Todd will discuss this with the SMEs (action item)
  • Question from Nathan
      • Why are the questions in orange on the document are procurement sensitive?
        • Per Todd, we are in procurement at this time and cannot address those questions highlighted in orange
        • The Program will circle back with the group as soon as they can

Recording for this discussion: 35:19 - 38:42

Question #4 The question “Has the patient completed a depression screening this month?” conflicts with the quarterly reporting requirement.

Question #7 What is CMS’ expectation around screening patients for depression? Most screen annually. 

    • Right now the EDIs are expected to assess patients annually under the QIP measure
    • EDIs have never been able to get clarity on the expectations of this new data collection 
    • They have been told to report the data quarterly for patients that were assessed in that quarter
    • Other times they have been told to report monthly for patients that were assessed in that month
    • Also have been told screening every patient at least quarterly and reporting on all patients quarterly
    • Ideally the EDIs would continue to meet the QIP requirements and provide assessments annually
    • Then report this additional data on those patients that were screened
    • Another concern is the timing of the reporting of the additional data
      • For example, I get an assessment this week, my receiving of treatment for mental health may not happen for 3-4 months for a variety of reasons
      • How do we address the timing of reporting the follow up that's feasible for the assessment actually being done allowing intervention to take place? Initially the reporting was going to be done by the end of the month.  There is not time for action to take place

Admission in Support of Transplant

Recording for this discussion: 39:37 - 58:48

  • Kathleen had a question about: "If admission reason is New to ESRD (because first episode is transplant), can the Admit Reason be Dialysis in Support of Transplant?"
    • Per Michael, if they have had a transplant and it is in America, then they're new to ESRD would be a transplant and then it should just be a dialysis in support of transplant as their second event
    • If they had a transplant somewhere else, and they were first coming into this country as a dialysis patient, it would just be new to ESRD dialysis
    • If Kathleen try's to send admission is the dialysis and support a transplant will she get and error that says "your admission reason can't be dialysis for support of transplant b/c previous admission is new ESRD?
    • Per Michael, need to confirm that if it's new to ESRD with a transplant modality
    • Per Yvette is it allowed and that can be the next admission; that's not new, it is how the system works today
  • Per Nathan - there was discussion if a patient is receiving dialysis and support of transplant and the transplant was determined to have failed.  How does that get handled from the dialysis perspective? Do we keep the admission?  Change the type of admission? Do we need a new admission reason? Discharge reason?
    • Per Yvette, when they were initially capturing the requirements for this feature from Lisa, she did not give different or a new discharge reason for dialysis and support of transplant. 
    • Right now the reason would still be death; that's where the conversation came up about who's going to enter the death form
    • Suggestions from EDIs said CMS should enforce it where the transplant facility would be responsible for creating that 2746 and not the dialysis facility
    • Nathan said the discussion was not if the patient dies but what if the transplant was determined it had failed and the patent has to go back on dialysis
    • Per Yvette, the decision was that a new admission would be created for that dialysis facility and the admission reason would be "dialysis after transplant failed"
    • Per Kathleen she believes a decision was not made and needed more discussion
    • Historically, direction has been given that the admission date back dates to the first treatment
    • A discussion needs to be, is that still the case or should there be a new admission?
    • Is it just changing the admission reason to fail?
    • This will have to be a program decision
    • Per Michael, Lisa wanted a second admission for the reason that she wanted to be able to track dialysis and supportive transplants apart from failures.  He feels this can be tracked a couple ways and neither are incorrect so the Program needs to help in how to handle this
    • EDIs need to understand the business rules the program is expecting for this
    • Once a decision is made we need to fully understand the impact this new admission and new discharge are going to have on QIP and five star and attribution to the clinic
    • Howard expressed a concern about doing a temporary one off admission; it will be difficult to communicate to frontline staff; may cause a confusion impacting the data
    • Second concern is NRAA system may not be able to accommodate this secondary admission
    • Suggest for CMS to step back and simplify this rather than make it complex
    • What is done now when a person who got a transplant comes in and you're giving backup dialysis and then become permanent failures, what do your clinics do now?
      • Per Nathan, they do not report the backup to EQRS b/c it's considered transient; internal documentation/paperwork is done but reported to EQRS

Open Forum

  • Nathan sent an email to CMS/Program last month around the implementation of the new vaccination module
    • Todd will review and follow up (action item)

Next meeting scheduled for  

Action Items:

  • Lisa will discuss with Yvette the verbiage/language surrounding the questions for depressed patients and cognitive decline.  In addition, review the EDIs feedback and suggestions Lisa Rees 
  • Per Lisa - she will have to get back to Vlad on when the release date for PPSV23 Lisa Rees 
  • Lisa will check with Yvette when she can go through the screens related to depressed patients and explain things, what is required, optional, etc Lisa Rees 
  • Lisa will discuss with CMS what is the expectation in terms of EDIs reporting the admissions, especially for short admissions in support of transplants Lisa Rees  
  • Per Lisa, she does not think there can be a retrospective look back at what has happened since EQRS was released but will take it back to CMS to find out Lisa Rees  
  • Lisa will need to ask the team where they plan to have the 2744 reports reside Lisa Rees  
  • Lisa will need to ask Michael why the acceptance criteria is limited to only the 6 fields listed in the Acceptance Criteria?  Lisa Rees 
  • Per Lisa, she does not think the effective date is included but will ask Michael for clarification Lisa Rees 
  • Per Lisa, she will need to check with Michael on whether a record can be updated through the UI Lisa Rees 
  • The definition for "Telemedicine" will be further clarified when Lisa takes the feedback to the team Lisa Rees 
    • 9/8/21 - Lisa is still looking into getting a definition for the EDIs
  • Leah Skrien asked if aside from Telemedicine if there is anything tied to treatment? Lisa will have the other PO's put together something explaining if anything is tied to treatment and bring to the next meeting Lisa Rees
    • 9/8/21 - Per Lisa, her understanding is yes, that Telemedicine was the only thing tied to treatment
  • Anitha will update the "new?" column field with the date the Kt/V "standard" option was moved into production Anitha Chintalapati
  • Nathan request since the Kt/V "standard" option is already in production, can they have the updated data dictionary, XSD, XML examples, error codes and any associated documentation.  Anitha will send the documentation Anitha Chintalapati
  • EDIs would like to understand how, if or when the Kt/V "standard" option will be used as part of the QIP adequacy measures and same for five-star. When will the standard Kt/V be included in QIP and five-star calculations? Need to get something out to the community/EDIs Ahmar Wazir Jason Clem
    • 9/8/21
      • Per Jason, there is no discussion to bring that it
      • On they post a muck list every December of new measures that might be implemented
      • At this time no plans to update the Kt/V measure
      • Per Howard they have a Kt/V with two methods, both are eligible and used in QIPs
      • If not going to use Kt/V, they need to tell people b/c Kt/V is being reported using standard methodology
      • Per Jason, an announcement was sent out on the standard method to all EQRS users - They are still just looking at the UKM two methods for QIP
      • Howard suggest to review the announcement again
      • Per Lisa, they will take this back to the QMVIG team for clarification and to get a definite answer

DateMilestone (M) / Task (T)DescriptionPhaseStatus
2/28/2021MCode deployed to pre-prod for testing.1Complete
3/15/2021 - 3/24/2021TEDIs perform integration testing.1Complete


MEDIs sign-off on integration testing.1Complete

3/24/2021 - 3/25/2021

TADO prepares for coding deployment.1Complete


MProduction deployment.1Complete
3/31/2021MProd-Preview environment contains refreshed prod data 2Complete
2/24/2021 - 3/10/2021 TReview of phase 2 codes and finalize list of codes.  Complete
3/11/2021 - 4/30/2021TADO perform coding updates and regression testing - Phase 2 (Patient Codes) 2Complete


MProd-Preview environment data refresh.2Complete


MRemaining Phase 2 (Patient Codes) deployed to pre-prod for testing.2Complete

5/4/2021 - 6/1/2021


EDIs performs integration testing - Phase 2 (Patient Codes) 
Starting 5/4 - EDIs submit prod file in prod environment and PP2-3.  This should be the SAME file for both environments.  Review discrepancies between the feedback files and validate codes.



MEDIs sign off-on integration testing - Phase 2 (Patient Codes) 2Complete

6/2/2021 - 6/4/2021

TADO prepares for coding deployment - Phase 2 (Patient Codes) 2Complete


MProduction deployment - Phase 2 (Patient Codes) 2Complete
6/4/2021MPhase 2 (Patient Codes) live in production.2Complete
3/10/2021 - 3/17/2021TReview of phase 3 codes and finalize list of codes.  3Complete
5/12/2021 - 06/08/2021TADO perform coding updates and regression testing - Phase 3 Clinical Codes/27283Complete


MProd-Preview environment data refresh.
6/4/2021 - 6/6/2021T

EDIs SHOULD NOT submit any PATIENT files during this time period in production (to ensure same patients are in PP2-3).


EDIs to drop file into PP2-3 to establish a baseline.



MCode deployed to pre-prod for testing - Phase 3 (Clinical Codes/2728).
Reopening September 2020 to March 2021 Clinical months for submission.

6/9/2021 - 7/6/2021

TEDIs performs integration testing.

Starting 6/9 - Re-drop same file from 6/7/2021 into PP2-3.  Review feedback files from PP2-3 and validate codes.



MEDIs sign-off on integration testing - Phase 3 (Clinical Codes/2728).3


7/7/2021 - 7/11/2021

TADO prepares for coding deployment - Phase 3 (Clinical Codes/2728).3Complete
7/12/2021MPhase 3 (Clinical Codes/2728) live in production.3Complete


MEDSM Implementation Complete (Phase 1 - 3).n/aComplete

7/12/2021 - 9/15/2021


Resubmission of Clinical Data Files (September to December). 

Open July 12, 2021 at 5 a.m. Pacific (8 a.m. Eastern) and close September 15, 2021 at 11:59 p.m. Pacific Daylight Time

9/15/2021 is the official closure date for the clinical months of September, October, November, and December 2020.

CMS highly recommends completing large data submissions prior to the official clinical closure date.





Data fully submitted and ready for measure and scoring calculations.

09/20/2021 - 02/28/2022T

Submit January-September 2021 EQRS Clinical Data, ICH CAHPS Attestations, and Clinical Depression Screening and Follow-Up Plan reporting in EQRS. Additionally, all subsequent months in 2021 will open for data submission on the first day of each month (i.e., October opens October 1; November opens November 1; and December opens December 1). 

02/28/2022MThe clinical closure date for all months in 2021 is February 28, 2022 at 11:59 PM PT.n/a

Data Submission (Errors & Warnings) Milestone Dates - By Phase

Phase No.

File Type

Code Bucket Name


ADO Completion Date

LDO Testing Start Date

Testing Completion Date

Production Date



Admit Reasons

11221, 11222, 11223, 11224, 11225







Patient Codes







Clinical Codes







2728 Codes





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