Aaron Thompsonx
Adrienne Adkins
Adrienne Rayx

Ahmar Wazir

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


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: 8Pjjo$z9 

Feature(s) UpdatePorsche

Dialysis in Support of Transplant

  • Adding a new Discharge Reason?
    • There was a need for a new discharge code for transplant patients who are admitted to a dialysis facility only for dialysis and support, not due to the failed transplant
    • Also it was believed the delay transplant function resolve following a transplant discharge option was in response to adding a new discharge reason
    • Per Kathleen, it was the suggestion but it has not been launched in the system at this time
    • Per Scott, the work has been developed and deployed into production but toggled off
    • If there are additional enhancements or requirements, EQRS would like to capture them, plan for development then turn the feature on

Admission and Supportive Transplant

    • Per Nathan there were some business rules the EDIs were trying to get clarity on
    • Scenario - A patient has a transplant and then they go to clinic A for this new admission reason of "dialysis in support of transplant"; if while they're getting those treatments, the physician says this transplant is failed and you need to go back to regular routine dialysis, How should the EDIs document that scenario?
    • The way it works now, without a separate discharge reason, is that initial admission would be changed to just a regular transfer in but then CMS would lose the visibility of the dialysis and supportive transplant
    • With out a discharge reason, there's no current valid discharge reason that applies to put the patient leaving clinic A and then immediately coming back in clinic A b/c it's not a transfer
    • The scenario brings up a broader discussion as to what are the business rules from the program side on how this should be documented for patients and what is the system behavior
    • Porsche and Scott will revisit the scenario above and request regarding documentation and system behavior
    • Question from Nathan - If the work has been done, have the EDIs been given the technical documents for all the most recent versions or have they been posted?
      • Per Scott, the technical documents have not been updated; we are in a holding pattern
    • Question from Nathan  - What do we do with pre-emptive transplants?
      • For example Nathan has never been on dialysis or is an AKI patient, gets a transplant, needs dialysis and support a transplant at a Medicare certified clinic
      • Are the EDIs expected to document that? Would it trigger a 2728?
      • Suggested that these questions be discussed with the program
      • This group would have opinions on how this is handled if the program wanted to talk through
      • Porsche has noted this down to talk to the program

HCP Flu Reporting to NHSN

    • Weekly vs Monthly
    • Deadline Status

3 2022 Dialysis Flu Vax Reporting Guidance.docx

    • See the Dialysis Flu Vax Reporting Guidance document above
    • Provides information on the weekly/monthly reporting
    • Training was completed 3/8/22; the CDC will be posting the training
    • Deadline has been moved to 4/14/22; this deadline should apply to all submitters
    • Question from Chris Brown - Have the EDIs received the file specs (CSV file spec) to batch the data to NHSN?
      • Per Nathan, they did receive it
      • Question from Rachelle - Are the EDIs expected to submit the Annual Flu Summary (once a year report) in addition to the regular last week of each month batching?
        • Shalon will check with the CDC on whether the expectation is to submit the Annual Flu Summary report in addition to the regular last week of each month batching
        • Per Chris Brown it was mentioned in the training that the annual is waived

Parathyroid Hormone (PTH) and Vitamin D

  • Michael and team met with CM (Abby and Nick) and received good information
  • The team then met with the EDIs and CM last Friday, 3/4
  • It was decided we do not need Vitamin D
  • There was discussion around the need for Parathyroid Hormone (PTH) and when we put PTH in production
  • Michaels team and the EDIs are meeting again this Friday, 3/11 to discuss further
    • Vlad and Nathan are checking internally to see if they can provide a timeframe of data to show that there are no adverse effects to PTH based on medication and no need to put this in EQRS
    • Howard will also see if he can get this data as well
  • If need to move forward with implementing PTH, the ranges that EDIs are using are similar standards of ranges
  • NRAA will not have to use 5 major labs across the country
  • We are in a good spot and ahead of schedule right now
  • Question from Nathan - Is there a timeline when EDIs will get expectations of what is to be reported? Planning to have a definitive plan by the end of PI17 to develop in PI18 and ready for July
  • Question from Vlad - Can the EDIs just give a comma delimited file with results for a whole year?
    • Not sure yet, more information will come from the 3/11 meeting

Open Forum



  • Nathan's items were discussed above
  • Nathan asked how to document IPD patients?
    • Originally he was told they should be put in as a modality as "other"
    • Nathan asked if that means they do not report monthly labs because there is no "other" labs
    • He was told that's not right
    • The last thing he heard was "how have you been doing them?"
    • Again, goes back to the discussion of needing documentation on the business rules, etc
    • Per Jason Clem,  EOCT took that question and passed it up to leadership and they are working on it
    • The reason why they asked Nathan how he was doing them was because EOCT knew IPD isn't a new item and these have had to have been reported in the past
    • How is it documented today?
      • On the treatment you put your setting as "In Center" and you select "other" b/c technically not CA or CCPD
      • It's In Center Peritoneal, its rare
      • It's still technically PD and should still be submitting their labs but the 2744 counts it that way
      • Nathan asked - if they put settings as "In Center", and their modality as "other" will they show up in the labs under Peritoneal?
        • Michael will need double check and let Nathan and Jason know the answer


  • No new items to discuss at this time


  • DCI has seen a significant number of rejections of their admission data with error 204
    • Started last Thursday,  3/3
    • 3/1 submitted 414 patients and 307 of them were successfully submitted; only seven 204 errors
    • 3/8 submitted 639 patients and only 50 were successfully submitted; 338 were rejected with the 204 error
    • This was mentioned in last Friday's EDI Touchpoint by FKC (Pandu).  It was giving a 204 error but the data was still saved. Michael did research and worked with Julie and Yvette on a fix
    • The fix went out into production Tuesday, 3/8 so going forward there should be no more 204 errors
    • Michael is working with Preston to see if he can run a query to determine which patients did or did not save per EDI and resubmit those for them
    • Vlad said EQRS team does not need to resubmit for DCI since they have an automatic process
    • The researched showed that if a patient was new to a unit (never at the unit before) and something was, that may have caused the 204 error
    • Revathy (FKC) asked when the fix went into production b/c they received a lot of 204 errors; only 10 of about 25,000 records submitted successfully
    • It may be a timing issue when FKC sent out the submissions.  
    • EQRS deploys according to their regular deployment schedule which is Tuesday and Thursday's between 8pm to 11pm Eastern time
    • For Tuesday and Thursday deployments, there are no notifications that are sent out to the EDIs
    • If there is a deployment needed outside of the regular deployment schedule, a notification will be sent out to the EDIs
    • Scott suggest KFC resubmit again because FKCs submissions that errored out may have been submitted before the fix was deployed into production


  • Unavailable for today's meeting

Next meeting scheduled for  

Action Items:

  • Todd requested that Nathan send the concerns surrounding the HCP Flu reporting to NHSN to him; Todd will be meeting with the CDC on Friday, 2/25 (Nathan)
  • Todd has the vaccination questions and will review with Porsche.  Feedback will be provided at the next Program Working Group meeting, 3/9 (Porsche/Todd)

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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