15.3 Medicare ESRD Payment, ESRD Networks, EQRS & the Survey Measures Assessment Tool

Why this belongs in Domain 3

The CSR outline's regulatory topic goes beyond the Conditions for Coverage. The CDR reference list includes the ESRD Quality Initiative, the Measures Assessment Tool (MAT) used by surveyors, and State Operations Manual Appendix X for transplant programs. Knowing how dialysis is paid, how data are reported and how surveyors judge outcomes explains many day-to-day rules, from who supplies phosphate binders to why albumin is drawn every month.

The ESRD prospective payment system (PPS)

Since 2011, Medicare has paid dialysis facilities a single bundled payment per treatment. The bundle covers the dialysis treatment plus renal dialysis services: labs, supplies and drugs such as ESAs, IV iron, IV vitamin D analogs and, since 2021, calcimimetics. Key features:

• Base rate: set each year by rulemaking. It is $281.71 per treatment for CY 2026.
• Adjustments: patient case-mix (age, body size, onset of dialysis, some comorbidities), facility low-volume and rural adjustments, wage index, and an outlier payment for unusually high-cost patients.
• Home dialysis training add-on, paid per training treatment.
• TDAPA (transitional drug add-on payment adjustment): new renal dialysis drugs are paid on top of the base rate for a set period, usually at least 2 years, before CMS folds their cost into the base rate. Calcimimetics followed this path.
• Oral-only drugs: since January 1, 2025, oral phosphate binders (sevelamer carbonate and hydrochloride, sucroferric oxyhydroxide, lanthanum carbonate, ferric citrate and calcium acetate) are paid through the TDAPA under the ESRD PPS instead of Part D. The dialysis facility therefore supplies them. Vadadustat, an oral HIF-PH inhibitor, received TDAPA for 2025–2026.
• AKI dialysis: Medicare pays ESRD facilities for dialysis for patients with acute kidney injury at a rate tied to the ESRD PPS base rate.

What this means for dietitians. Because the bundle includes these drugs, binder and anemia protocols affect facility costs, and binder supply now runs through the facility. Renal MNT cannot be billed separately for patients on maintenance dialysis (42 CFR 410.132(b)(1)); dietitian services are part of the dialysis payment.

ESRD Networks

CMS contracts with ESRD Network Organizations, one for each of 18 geographic areas, to improve quality and support patients. Networks:

• run regional quality-improvement projects, for example on home dialysis, transplant waitlisting, vascular access and infection prevention;
• take patient grievances and help with difficult transfers and involuntary discharges; a facility must give the patient and the Network 30 days' notice of a planned involuntary discharge;
• collect and validate data, and help with emergency and disaster preparedness.

Under 42 CFR 494.180(i), each facility must cooperate with its Network, act on its recommendations and pursue Network goals. The MAT tells facilities to use their Network's goals as targets for aggregate patient outcomes.

Data reporting: EQRS and CMS forms

Facilities must submit data electronically as CMS specifies (§494.180(h)). The ESRD Quality Reporting System (EQRS), which replaced CROWNWeb, holds patient events, monthly clinical values (for example, calcium, hemoglobin, Kt/V and albumin) and QIP reporting data. Key forms:

• CMS-2728 (ESRD Medical Evidence Report): completed when a patient starts dialysis or gets a transplant. It records entitlement data, lab values at the start of treatment and pre-dialysis care, including prior care by a kidney dietitian.
• CMS-2746 (ESRD Death Notification).

Nutrition values entered each month feed QAPI dashboards, the Dialysis Facility Reports and public reporting.

The survey process and the Measures Assessment Tool

State survey agencies inspect dialysis facilities for CMS using the ESRD Core Survey process, standardized worksheets and V-tags that map each CfC requirement. The Measures Assessment Tool (MAT, version 2.5) summarizes the clinical values surveyors use to judge whether the team recognized and acted on out-of-range outcomes. Surveyors cite a facility for failing to act, not for an individual out-of-range value.

Some MAT values come from older guidelines (for example, KDOQI 2006 iron targets and KDIGO 2009 phosphorus). Current guidelines may differ, such as the KDIGO 2026 anemia guidance. On the exam, answer survey questions with the survey tool and clinical questions with the current guideline.

Public reporting

Dialysis Facility Care Compare shows star ratings from 1 to 5, quality measure results and patient-experience data. ESRD QIP scores are also public, and facilities post their QIP performance certificates. These reports make nutrition-related outcomes, such as hospitalization and transfusion ratios, visible to patients.

Transplant program requirements

Transplant programs have their own Medicare conditions of participation (42 CFR 482.72–482.104), which surveyors apply using SOM Appendix X. Relevant to dietitians:

• §482.94(e) Nutritional services: nutrition assessment and diet counseling by a qualified dietitian (meeting state requirements and registered with CDR) must be available to all transplant patients and living donors.
• §482.94(a): each transplant patient and living donor must be under a multidisciplinary team coordinated by a physician.
• §482.94(c): the program must tell the patient and the dialysis facility about listing decisions, and must notify them within 10 days of removing a patient from the waiting list for reasons other than death or transplant.