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Post-Acute Care Quality Programs





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EQRS Clinical Data Submission and ESRD QIP Attestation Deadlines Approaching for the December 2024 Reporting Month

The Centers for Medicare & Medicaid Services (CMS) End Stage Renal Disease (ESRD) Quality Reporting System (EQRS) clinical data submission deadline for the December 2024 reporting month and payment year (PY) 2026 ESRD Quality Incentive Program (QIP) attestations is *March 3, 2025, at 11:59 PM Pacific Time (PT)*. This deadline applies to all collection types (Hemodialysis and Peritoneal Dialysis) and to all submission methods. The EQRS submission deadlines for calendar year 2024 data are listed below for the following: 

1. EQRS Clinical Data

2. Clinical Depression Screening and Follow-Up Assessments

3. In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Attestation

4. Facility Commitment to Health Equity (FCHE) Attestation (*new reporting measure beginning in payment year 2026*).

5. NHSN ESRD Data

EQRS Clinical Data Deadlines

December EQRS clinical data submission began on December 1, 2024, and will end on March 3, 2025, at 11:59 PM Pacific Time (PT). For additional information on how to submit data in EQRS, refer to the Education [ https://pr6fm49ab.cc.rs6.net/tn.jsp?f=0017CJ4NwbF5ISfVuJ3M9ADckMDSQC6_waSVNsGMCCtPTGTbZr1ZiGhOhoeR7-z-QpS4h9eEBhNbTjPX3bp37zXO4gqwFZqRRbsrFoBs_Of5N-bPpXobZVub9VMPm81eQbBj0VUaj2p0Il-W1Vw62rrwSXAgq8tEBd7qG_vWrYxR14=&c=O3IQpHgaHOEnB5mNZ6W58EwNn8C4WmqbTsfV-kigYqIAtal5r-TDKA==&ch=mndqtXAb3cqfTyqFhxPEkbAl56uP5syZtj_2QUxNmmQQptOV5Om1Aw== ] page on www.MyCROWNWeb.org [ https://pr6fm49ab.cc.rs6.net/tn.jsp?f=0017CJ4NwbF5ISfVuJ3M9ADckMDSQC6_waSVNsGMCCtPTGTbZr1ZiGhOjRX3ric8qUey9NwlwWWQkvwP8xFNYntR0hYGd6zgXuhiQltj8RaN_X7aaFA7Tgta-iTzDOgOxa6JlFqcC778oZcHpQslNXj8pAsAm6yFkqc&c=O3IQpHgaHOEnB5mNZ6W58EwNn8C4WmqbTsfV-kigYqIAtal5r-TDKA==&ch=mndqtXAb3cqfTyqFhxPEkbAl56uP5syZtj_2QUxNmmQQptOV5Om1Aw== ]. *Dialysis facilities must submit EQRS clinical data by the deadline. Not submitting the required data by these deadlines puts your facility at risk for an ESRD QIP Program payment reduction.*

Clinical Depression Screening and Follow-up

To enter clinical depression screenings in EQRS:


* Log in to EQRS.
* In the Patient Registry, click *Patients*.
* Under Patients, click *Clinical Depression*. The "Clinical Depression Screening and Follow-up Reporting" screen displays.
* Under *Assessment Period*, click the 01/01/2024-12/31/2024 option.
* Select *Required* from the "Depression screening status"
* Review the list of required patients and click *Report* for the desired patient. The "Clinical Depression Screening and Follow-up Reporting" screen appears.
* Review the screening options and select the most appropriate option. Click *Submit*.
* EQRS displays a time stamp of the clinical depression screening that was submitted and displays the “Clinical depression assessment reported successfully” message.

ICH CAHPS Attestation

Attestations for the ESRD QIP ICH CAHPS measure should be submitted if your facility _is not eligible_ and would not like to receive a score for the measure. For more information on facility eligibility, please review https://www.cms.gov/files/document/cy-2024-technical-measure-specifications.pdf.

To submit an ICH CAHPS attestation in EQRS:


* Log in to EQRS.
* In the Patient Registry, click *Facilities*.
* Under Facilities, click *Attestation*.
* Click *In-Center Hemodialysis CAHPS (ICH CAHPS)*. The "In-Center Hemodialysis CAHPS (ICH CAHPS) Attestation" screen displays.
* Click the box next to “I attest that my facility is *not eligible*for the ICH CAHPS clinical measure because it treated fewer than 30 eligible patients over the course of the entire eligibility period (i.e., Calendar Year 2023).”
* Enter your *First Name* and *Last Name*. Click *Submit*.

_NOTE: If your facility is eligible for the ICH CAHPS measure, leave these fields blank._

Facility Commitment to Health Equity (FCHE) Attestation

CMS is currently assessing the continued inclusion of the FCHE reporting measure in ESRD QIP scoring. Any change will be communicated through required CMS channels. Until a change is announced, FCHE attestations should be submitted using the process described below.

To submit the FCHE attestation:


* Log in to EQRS.
* In the Patient Registry, click *Facilities*.
* Under Facilities, click *Attestation*.
* Click *Commitment to Health Equity.* The "Commitment to Health Equity Attestation" screen displays.
* Click the *Assessment Period: 01/01/2024-12/31/2024* Note: if your facility has already submitted an attestation, this assessment period will not display. Scroll down to the "Submitted Attestation" section on this page to view or edit the submission for this assessment period.
* On the Commitment to Health Equity Attestation page, review the attestation descriptions under each domain. Select all that apply. _If your facility did not perform the activity, leave the box blank_.
* If your facility performed all activities in the domain, you may click *All the above: I attest that my facility engages in all of the above activities. *
* Once you have completed your attestations, click* Submit Attestation.*

Final Reminder

CMS strongly recommends that facilities complete large data submissions and audit batch submitted data well before the submission deadlines to ensure accurate and timely data submission.

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Center for Clinical Standards and Quality








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