The Renal Beneficiary and Utilization System (REBUS)/Program Management and Medical Information System (PMMIS) Database for the End Stage Renal Disease (ESRD) Program

The REBUS/PMMIS was designed to track current ESRD patient and facility information. The REBUS/PMMIS Database contains basic medical and program management data related to services provided by Medicare-approved ESRD facilities in the treatment of dialysis and kidney transplant patients.

File Creation

The REBUS/PMMIS Database contains information for all Medicare beneficiaries with ESRD and all Medicare-approved renal providers. The database has been expanded to include non-Medicare patients. Beneficiary-specific data maintained in the REBUS/PMMIS are collected on enrollment/ entitlement documents originating from SSA district offices, renal providers, and inpatient and outpatient claims. Provider certification information, minimum utilization rates, and other provider characteristics are collected from CMS(previously HCFA) regional offices, ESRD network organizations, and from Fiscal Intermediaries through Common Work File (CWF) host sites. Aggregate patient population data are collected on HCFA Form 2744 and submitted annually to CMS by renal providers through the ESRD networks.

File Maintenance

CMS requires the 18 ESRD Networks to maintain an electronic database of beneficiary and provider data obtained from the treatment facilities (i.e., dialysis units and transplant centers) within their Network. The facilities complete the required HCFA-2728 Medical Evidence, HCFA-2746 Death Notification, and HCFA-2744 Annual Facility Survey forms and forward them to the ESRD Networks for data entry and maintenance. The Networks enter and edit the collected data utilizing the ESRD Data Entry and Editing Software (EDEES) supplied to the Networks and maintained by CMS.

Hard copy data collected on the CMS Forms are reviewed and verified by the ESRD Networks prior to keying the data into the EDEES. Keyed data are processed through consistency checks and logic edits. Valid HCFA-2728 and HCFA-2746 records are posted to the EDEES database and are electronically transmitted to CMS on a monthly basis. Records which do not pass the edits in the EDEES are flagged as being in error and are not transmitted to CMS until the errors have been researched, corrected and accepted by the EDEES.

Upon receipt of the HCFA-2728 and HCFA-2746 data from the Networks, the data are reviewed, merged into one file and then uploaded to REBUS. The beneficiary-specific records are processed through a series of edit checks. Valid records and records with errors are posted to an on-line file for correction, validation, and further processing.

CMS reconciles the REBUS/PMMIS data with other beneficiary data obtained from the Enrollment Data Base (EDB) and the National Claims History (NCH) billing data file. When discrepancies arise, CMS either overwrites the REBUS data provided by the Network(s) or notifies the Network(s) or asks the Network(s) to research and report back to CMS. Edit reports identifying the data discrepancies are prepared by CMS staff in the Office of Clinical Standards (OCSQ) / Information Systems Group (ISG) and mailed to the Networks each month. The Networks may make changes to the REBUS/PMMIS data via the REBUS M204 on-line application, or they may notify OCSQ/ISG who will make the necessary changes.

In a nightly batch process, REBUS/PMMIS beneficiary-specific data are updated with data from the EDB. The EDB provides the REBUS/PMMIS with its most-current value of the Health Insurance Claim Number (HICN or HIC) and the associated Beneficiary Identification Code (BIC), as well as other data elements such as date of birth, sex, entitlement reason, race and date of death. The REBUS also updates data elements in the EDB in two different ways.

The REBUS initiates a process twice a day that identifies beneficiaries with new information in the REBUS/PMMIS database that may affect ESRD coverage. Once the beneficiaries are identified, the REBUS recalculates ESRD coverage periods for those beneficiaries and utilizes a communications thread available to M204 (HORIZON) to interactively update the coverage data in the EDB. Additionally, OCSQ/ISG analysts regularly use EDB-designed screens to directly log onto the EDB and examine specific data values in order to aid in resolving issues raised by ESRD Network personnel. The analysts may then update necessary data elements in the EDB to reconcile the data issues.

Twice each year, the 18 ESRD Networks are asked to provide CMS with a census from their databases of ESRD patients alive on a particular date. This patient status file is to contain the most current known treatment (i.e., dialysis or transplant) information for every person supported by the Network. This information is used to update treatment information contained in the REBUS/PMMIS Patient Status Record. If the information provided affects a beneficiary's ESRD termination date, then that new date is passed to the EDB so that it can also be updated in the EDB. Patients who are listed in this census but who are not already in the REBUS/PMMIS are presumed to be receiving ESRD treatment independently of the Medicare program. Such patients are entered into the REBUS/PMMIS for statistical enumeration purposes.

REBUS/PMMIS beneficiary-specific data are also updated each month with billing data obtained from the NCH database. Bills for a transplant for new ESRD beneficiaries generate new ESRD identification records, while bills associated with continued ESRD services for established ESRD beneficiaries result in updates to existing identification records.

In addition to updating the files which house identifying data for each ESRD beneficiary, the REBUS Quarterly Dialysis records and Inpatient Stay records are also updated based on the information obtained from the NCH. The REBUS/PMMIS hospital records and quarterly summaries of dialysis treatments are derived from the CMS paid claims records maintained in the NCH.

REBUS/PMMIS utilization data are also updated each month with claims data from the Common Working Files (CWFs). Provider certification information, minimum utilization rates, and other provider characteristics are collected from CMS regional offices, ESRD Network Organizations, and from Fiscal Intermediaries (FIs) through CWF "host" sites. HCFA-382 method selection data are collected at each of the nine CWF sites. On a weekly basis, the CWF receipt control process then makes files available to the Division of Systems Support within the OCSQ/ISG for use in updating the REBUS Method Selection data each month.

The Networks and United Network for Organ Sharing (UNOS) each collect portions of the REBUS/PMMIS transplant data. If a patient's first treatment modality is transplant, the Network collects the HCFA-2728 entitlement form. If transplant is not the patient's first modality, the Network tracks the patient's dialysis activity prior to a transplant. Some of the transplant data collected by the HCFA ESRD program is the same as that collected by UNOS for their OPTN data system.

Among other items, UNOS collects data on patients on the transplant wait list; donor and recipient data when a transplant occurs; and routine follow-up information on the patient and the transplanted kidney. UNOS sends their transplant data to CMS, which is then loaded into the REBUS/PMMIS. UNOS kidney transplant records are transmitted to CMS weekly. CMS electronically attempts to match UNOS records to existing master Identification records contained within the REBUS/ PMMIS. If a perfect match on name (first six positions of the surname and first initial of the first name), sex, date of birth, and BIC is made, then the transplant record is posted in the transplant file and in the Identification file in the REBUS/PMMIS. If no match is made, an Identification record is created in REBUS based solely on receipt of the transplant record. If a partial match is made on three out of the five data elements, then the transplant record is posted to a partially matched record and correction of mismatched elements are electronically returned to UNOS.

In addition to the monthly transplant data transmissions provided by the UNOS to the REBUS/PMMIS, UNOS transmits several tape data files to CMS on a quarterly (i.e., January, April, July, and September) basis as well. The data from these files are used primarily for research purposes and to provide information on other types of organ transplants in addition to kidneys. The UNOS data files transmitted to CMS include the following:

Kidney Transplant Recipients
Kidney Follow-ups
Kidney Wait List
Kidney Removals List
Extra-Renal Wait List
Extra-Renal Removals List
Liver Transplant Recipients
Liver Follow-ups
Thoracic Transplant Recipients
Thoracic Follow-ups
Pancreas Transplant Recipients
Pancreas Follow-ups
Transplant Recipient Registration File (for all transplant organ types)

CMS sends blank HCFA-2744 Annual Facility Survey forms to the ESRD Networks at the end of each calendar year which they in turn are to forward to their dialysis units and transplant centers. The facilities complete these forms and return them to the Networks for data entry of the provider-specific and aggregate patient population data supplied by the facilities. The Networks either key the information directly into the REBUS or key the data into the EDEES and then forward an electronic data file to CMS.

Provider certification and characteristic data are updated continually as information is received from CMS Regional Offices, ESRD Network Organizations, and State Survey Agencies in the form of certification letters received by the OCSQ/ISG. At least monthly, a report is run from CMS's On-line Survey Certification and Reporting (OSCAR) System which is compared to the previous month's report to identify new facilities that need to be added to the REBUS/PMMIS.

File Structure and Usage

The REBUS/PMMIS is a mission critical system that is used by CMS and the renal community to perform their duties and responsibilities in monitoring the Medicare status, transplant activities, dialysis activities, and Medicare utilization (inpatient and physician-supplier bills) of ESRD patients and their Medicare providers, as well as in calculating the Medicare-covered period of ESRD.

The REBUS is a M204 automated interactive database access tool for the ESRD PMMIS patient and provider data. REBUS was developed to provide a centralized database for CMS ESRD data and to facilitate generating reports and editing these data.

The REBUS/PMMIS Database contains beneficiary-specific data, provider characteristic data, aggregate patient population information, UNOS wait list data, and SSA district office address information.

Beneficiary-specific data are contained in nine types of records: identification records, patient status records, medical evidence records, transplant records, transplant follow-up records, quarterly dialysis records, ESRD method selection records, inpatient stay records, and death notice records. Each record contains information for one beneficiary. Each beneficiary has an identification record and may also have other beneficiary-specific types of records. Beneficiary-specific data elements provide information on beneficiary characteristics, primary disease, first date of ESRD care, dialysis and transplantation, hospitalization and outpatient care, and date and cause of death.

Provider characteristics and aggregate patient population data are contained in the facility certification/survey record. Each facility certification/survey record represents one provider. The Facility Certification portion of the record captures certification and other information about an ESRD facility approved by Medicare to provide kidney dialysis and transplant services. Facility Certification data are also maintained for some facilities that may not be Medicare-approved (e.g., some Department of Veterans Affairs (DVA) facilities), however, REBUS does not house full identifying information on the non-certified facilities. The Facility Survey portion of the record captures activities performed during the calendar year as well as aggregate year-end population counts for both Medicare beneficiaries and non-Medicare patients.

Data Structure and Usage

The REBUS/PMMIS Identification Record (IDENDATA)includes basic beneficiary data such as demographic data elements and date of death; Part A and Part B entitlement and termination information; and ESRD-specific information concerning drug use such as Erythropoietin (EPO), dialysis, cause of death, and transplants.

The REBUS/PMMIS Patient Status Record (STATDATA) includes data describing the verified renal status of a beneficiary, including a patient's modality, most-recent treatment setting, transplant status and death status.

The REBUS/PMMIS Medical Evidence Record (MEDATA) contains data elements concerning dialysis, transplant, and self-care training collected from the HCFA-2728 ESRD Medical Evidence Report form. A beneficiary may have one medical evidence record for each period of ESRD entitlement. An HCFA-2728 is completed by the provider within 45 days of when the patient has been determined to have ESRD and is signed by the physician after a patient's regularly scheduled course of therapy begins. The HCFA-2728 serves to: 1) establish Medicare eligibility and provide the medical determination necessary for ESRD individuals who previously were not Medicare beneficiaries, 2) reclassify previous Medicare beneficiaries as ESRD patients, and 3) to provide demographic and diagnostic information on all new ESRD patients regardless of Medicare entitlement. The information captured from this report are used to register all ESRD patients with the United States Renal Data System (USRDS) where the data are used for epidemiological studies.

The REBUS/PMMIS Transplant Record (TRANDATA) was expanded in 1994 to include all transplant details as reported by the UNOS. Data elements in the transplant record include beneficiary identifiers; hospital stay data such as date of transplant and number of days in a hospital; blood transfusion data; organ donor data such as sex, age, blood information, and kidney infections at harvest; and pretreatment information.

The REBUS/PMMIS Transplant Follow-up Record (TXFUDATA) was also expanded in 1994 to include all follow-up details as reported by the UNOS. Beneficiaries receiving transplants continue to be traced until the patient dies or until the graft no longer functions. Beneficiaries may have more than one transplant follow-up record. Data elements in the transplant follow-up record include a beneficiary identifier; transplant surgeon name; time period of follow-up; and problems, procedures, and therapies performed during the follow-up period such as graft failure, graft removal, and immunosuppressive therapy. These data are updated monthly with new and corrected records provided by the UNOS.

The REBUS/PMMIS Quarterly Dialysis Record (DIALDATA) includes dialysis type, dates of treatment, and EPO information. The record also contains aggregated information by provider for all dialysis claims received during a quarter. A beneficiary may have multiple dialysis records, depending on the number of providers who submit claims.

The REBUS/PMMIS Inpatient Stay Record (IPDATA) contains data elements related to an inpatient stay such as provider number, hospital stay dates, Diagnosis Related Group (DRG) code, surgery information, dialysis type and EPO data. Each record represents a hospital stay for beneficiaries who were hospitalized for more than one day. A beneficiary may have more than one inpatient stay record depending on the number of stays.

The REBUS/PMMIS Method Selection Record (METHDATA) includes a beneficiary identifier; death indicator; claims data obtained from the CWF such as the ESRD payment method chosen by the beneficiary, provider number, and dialysis type; and historical ESRD selection data such as dialysis type and its related option years and the ESRD payment method chosen by the beneficiary. Beneficiaries submit the ESRD Beneficiary Selection form (HCFA-382) to select and provide information for the method of reimbursement by the Medicare program for home dialysis services. The method selection record may be updated at any time during the year, but beneficiary payment data can be changed only once during the year. Any additional changes are effective the next calendar year.

The REBUS/PMMIS Death Notice Record (DNDATA) contains data elements identifying the date, place, and cause of death for a beneficiary and other death notice information collected from HCFA Form 2746. The primary provider completes the HCFA-2746 within 30 days of death, regardless of the location of the beneficiary's death.

The REBUS/PMMIS Facility Certification/Survey Record (CERTDATA & SURVDATA) contains provider-specific and aggregate patient population data on beneficiaries treated by that provider obtained from the Annual Facility Survey form (HCFA-2744). The data elements include basic provider information such as provider certification and type of ownership; aggregated dialysis patient data such as the number of patients, number of deaths, and number of patients receiving different types of dialysis; dialysis treatment data; kidney transplant data such as number of transplants, type of transplants, and number of patients awaiting transplants; and the total number of each method used to obtain kidneys for transplants. The accuracy of the Facility Survey depends on complete reporting by each facility and full reporting by all facilities.

The REBUS/PMMIS Wait List Record (WAITDATA) contains data collected by the UNOS at the time potential transplant recipients are placed on the kidney waiting list. The Wait List data in REBUS represent all potential kidney transplant recipients who are awaiting transplantation. These data are updated monthly with new and corrected records provided by the UNOS. Since these data are dependent on receipt of information at UNOS, REBUS users may experience a delay in receipt of any information regarding who has been added to the UNOS Wait List for a kidney transplant. Any active Wait List data shown in REBUS are only pertinent to the moment the data were copied by UNOS, and thus cannot be used for calculation of mean or median waiting times.

The REBUS/PMMIS SSA District Office Address Record (ADDRDATA) contains address information for each of the local SSA District Offices. This data has not been updated since the implementation of the current REBUS.

The data maintained in the ESRD REBUS/PMMIS Database is utilized to prepare ad hoc reports and perform analyses in response to requests from various CMS component groups, the DHHS, Congress, the renal professional community, media, and various research organizations. For example, the REBUS/PMMIS Database serves the needs of CMS and the DHHS in support of program analysis, policy development, and epidemiological research. The USRDS, funded and directed by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institute of Health (NIH), also relies on the REBUS/PMMIS Database as its major source of data.

Methods of Access

ESRD/REBUS/ PMMIS data are provided to researchers on an ad hoc basis. Further information about the ESRD/REBUS/PMMIS Database can be obtained by contacting the OCSQ /ISG. Public Use Files (PUFs) are available for some of the ESRD/REBUS/PMMIS data. Further information about PUFs is provided in the Public Use Files Data chapter.

Migration of Data

REBUS now serves as the primary mechanism for accessing information housed in the PMMIS - the legislatively mandated data repository for the ESRD Program. The OCSQ/ISG is developing the Renal Management Information System (REMIS), which is an information system that will support the ESRD Program and will ultimately replace the REBUS. The redesign of the REBUS/PMMIS into the REMIS/PMMIS will result in the migration of the legacy data from an M204 database structure to an Oracle relational database structure. In the Spring of 2000, REMIS is expected to perform all the functions of REBUS and more. The new REMIS/PMMIS will support and improve data collection, validation, and analysis of the ESRD patient population, as well as provide timely and accurate analysis information to the ESRD Networks, dialysis facilities, transplant centers, and research organizations via a web-based decision support system and data administration facility. The new REMIS/PMMIS will significantly improve support for ESRD program analysis, policy development, and epidemiological research.

The EDEES utilized by the ESRD Networks to enter and edit the collected CMS forms data is also being replaced by the Standard Information Management System (SIMS), which is due to be fully operational by the beginning of 2000.

List of Data Elements

Lists of the data elements contained in the REBUS/PMMIS Database, along with brief definitions and coding schemes, will be included in the future on the CMS web site at www.cms.hhs.gov. Separate lists are provided for each record type (including both versions of the transplant record). The Facility Certification Survey record is divided into two lists: ESRD Facility Certification and ESRD Facility Survey.