 Participants will:
• Identify quality reporting by Centers for Medicare
& Medicaid Services (CMS) for Ambulatory Surgery
Centers (ASCs)
• Understand the history of quality measure development
• Learn to collect and report the data for the required quality measures

 Centers for Medicare & Medicaid Services (CMS) / State
 Life Safety Code (LSC)
 Occupational Safety and Health Administration (OSHA)
 Food and Drug Administration (FDA)
 Environmental Protection Agency (EPA)
 Drug Enforcement Agency (DEA)
 Federal Aviation Administration (FAA)

American Recovery and Reinvestment Act of 2009
 Stimulus money provided the down payment for a nationwide effort to reduce health care associated infections in standalone or same-day surgical centers.
 Interpretive Guidelines for the Conditions for Coverage provide guidance on the meaning of the rules and further advice on how ASCs should comply.
 State Operations Manual http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/som107ap_l_ambulatory.pdf
 Infection Control Surveyor Worksheet http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/som107_exhibit_351.pdf

 Medicare requires ASCs to comply with the 2000 edition of the Life Safety Code, updated and published by the National Fire Protection
Association.

 In April 2014, CMS announced the proposal to adopt the National Fire Protection Association’s (NFPA)
2012 editions of the Life Safety Code (LSC) and the
Health Care Facilities Code (HCFC).
◦
The requirement is currently a 1-hour minimum separation between
ASCs and other adjacent tenants/occupancies. This proposal would require a 2-hour separation in un-sprinkled buildings.
◦
More extensive alarms, and more elaborate medical air compressors and clinical vacuum on piped medical gas systems would be required which would cause needed upgrades to systems.
◦
For windowless anesthetizing locations: “The ASC must have a supply and exhaust system that (i) Automatically vents smoke and products of combustion, (ii) Prevents recirculation of smoke originating within the surgical suite, and (iii) Prevents the circulation of smoke entering the system intake. These requirements would impact the design, installation, and operation of the entire HVAC system for a facility.

 Occupational Exposure to Bloodborne Pathogens
29CFR 1910.1030
http://www.osha.gov/pls/oshaweb/owadisp.show_doc
ument?p_table=standards&p_id=10051
 OSHA has two different types of inspections:
• Enforcement inspections determined by OSHA
(unannounced)
• Consultation services that are requested by the facility
(scheduled) http://www.osha.gov/dcsp/smallbusiness/consult.htm


http://www.fda.gov/Safety/Recalls/default.htm
http://www.fda.gov/Safety/MedWatch/default.htm


 Resource Conservation and Recovery Act (RCRA) gives the EPA the authority to control hazardous waste from the “cradle to the grave”. This includes the generation, transportation, treatment, storage, and disposal of hazardous waste.
Hazardous Pharmaceutical Waste under the RCRA:
• Contains a “P” (acutely hazardous) or “U” (toxic) listed waste as the sole ingredient; or
• Exhibits at least one “characteristic” of a hazardous waste
 It is recommended to involve the center’s consulting pharmacist to make certain the center is in compliance with federal and state regulations.



 These surveys examine:
• the process of transporting radioactive materials
• training of ASC staff in handling radioactive materials
• the ASC’s policies on radioactive materials (process for shipping of materials, process for return of product, how to handle hazards, staff training, consultant physicist, etc.)

Rule Reference
CY 2015
OPPS/ASC
CY 2014
OPPS/ASC
CY 2013
OPPS/ASC
FY 2013
IPPS/LTCH PPS
CY 2012
OPPS/ASC
CY 2011
OPPS/ASC
CY 2010
OPPS/ASC
CY 2009
OPPS/ASC
CY 2008
OPPS/ASC
Proposed or
Final Rule
Federal Register (FR) Reference https://www.federalregister.gov
Final
Final 78 FR 75122
Final
Final
Final
Final
77 FR 68492
77 FR 53637
76 FR 74492
75 FR 72109
Final
Final
Final
74 FR 60656
73 FR 68780
72 FR 66875
Program Highlights
1 new claims-based measure- “dry run” 2015
Finalized 3 measures
No additional measures
Finalized requirements
Finalized 8 measures
Discussed/Not implemented
Discussed/Not implemented
Discussed/Not implemented
Discussed/Not implemented

ASC-4
ASC-5
ASC-6
ASC-7
ASC-8
Number
ASC-1
ASC-2
ASC-3
Measure Title
Patient Burn
Patient Fall
Wrong Site, Wrong Side,
Wrong Patient, Wrong
Procedure,Wrong Implant
Hospital
Transfer/Admission
Prophylactic Intravenous
(IV) Antibiotic Timing
Type of
Measure
Claims-Based
Claims-Based
Claims-Based
Claims-Based
Claims-Based
Safe Surgery Checklist Use Web-Based via
QualityNet secure portal
ASC Facility Volume Data on Selected ASC Surgical
Procedures
Influenza Vaccination
Coverage among
Healthcare Personnel
Web-Based via
QualityNet secure portal
Web-Based via NHSN
Data Collection
Date
January 1-
December 31,
2014
January 1-
December 31,
2014
January 1-
December 31,
2014
January 1-
December 31,
2014
January 1-
December 31,
2014
January 1-
December 31,
2014
January 1-
December 31,
2014
October 1, 2014-
March 31, 2015
Data Reporting
Date
January 1-
December 31,
2014
January 1-
December 31,
2014
January 1-
December 31,
2014
January 1-
December 31,
2014
January 1-
December 31,
2014
January 1-
August 15, 2015
January 1-
August 15, 2015
Affected Groups
Medicare Part B fee for service patients
Medicare Part B fee for service patients
Medicare Part B fee for service patients
Medicare Part B fee for service patients
Medicare Part B fee for service patients
All patients
All patients through May 15,
2015
Health Care
Personnel

Number
ASC-9
ASC-10
ASC-11 Voluntary
ASC-12
Measure Title
Endoscopy/Polyp
Surveillance: Appropriate
Follow-Up Interval for
Normal Colonoscopy in
Average Risk Patients
Endoscopy/Polyp
Surveillance: Colonoscopy
Interval for Patients with a
History of Adenomatous
Polyps – Avoidance of
Inappropriate Use
Cataracts- Improvement in
Patient’s Visual Function within 90 days following
Cataract Surgery
Facility Seven-Day Risk
Standardized Hospital Visit
Rate after Outpatient
Colonoscopy
Type of
Measure
Web-Based via
QualityNet secure portal
Web-Based via
QualityNet secure portal
Web-Based via
QualityNet secure portal
Claims-Based
Data Collection
Date
April 1-
December 31,
2014
April 1-
December 31,
2014
January 1,-
December 31,
2015
Paid Medicare
Fee for Service
Claims from
January 1, 2016
– December 31,
2016
Data Reporting
Date
January 1-
August 15, 2015
January 1-
August 15, 2015
January 1, August
15, 2016
Sampling
Paid Medicare
Fee for Service
Claims from
January 1, 2016 –
December 31,
2016
Affected Groups
Sampling
Sampling
Paid Medicare Fee for Service Claims


 To date- 9 versions (April 2012-June 2014)
 Latest version- 4.0 (June 2014)
 Measure specifications
 Data collection and submission
 Quality Data Codes (QDCs)


•
•
•
•
*
Data submission began in CY 2012




Claims Based Reporting–Quality Data Codes (QDCs)
• Patient Burn
• Patient Fall
•
Wrong Site, Side, Patient, Procedure, Implant
• Hospital Admission/Transfer
• Prophylactic IV Antibiotic Timing
Web Based Reporting via QualityNet Secure Portal
( www.qualitynet.org
)
• Safe Surgery Check List Use
• ASC Volume of Selected Procedures for all-patients
Web Based Reporting Via Centers for Disease Control and Prevention (CDC) National Health Care Safety
Network (NHSN) ( www.cdc.gov/nhsn/index.html
)
•
Influenza Vaccination Coverage Among Health Care Personnel

The ASC quality measures, G codes, and their descriptions are included in Table 6 below:
ASC Quality Measures G-code Long Descriptor
Patient documented not to have experienced any of the following events: a burn
Patient burn prior to discharge; a fall within the facility; wrong site/side/patient/procedure/implant event; or a hospital transfer or hospital
G8907 admission upon discharge from the facility.
G8908 Patient documented to have received a burn prior to discharge
Patient fall in ASC facility
G8909 Patient documented not to have received a burn prior to discharge
G8910 Patient documented to have experienced a fall within ASC
G8911
Patient documented not to have experienced a fall within Ambulatory Surgical
Center
Wrong site, wrong side, wrong patient, wrong procedure, wrong implant G8912
Hospital transfer/Admission
G8913
G8914
G8915
Patient documented to have experienced a wrong site, wrong side, wrong patient, wrong procedure or wrong implant event
Patient documented not to have experienced a wrong site, wrong side, wrong patient, wrong procedure or wrong implant event
Patient documented to have experienced a hospital transfer or hospital admission upon discharge from ASC
Patient documented not to have experienced a hospital transfer or hospital admission upon discharge from ASC
Timing of Prophylactic antibiotic administration for SSI prevention G8916
G8917
G8918
Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis, antibiotic initiated on time
Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis, antibiotic not initiated on time
Patient without preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis




Released August 2012
The final rule can be accessed at
( https://s3.amazonaws.com/publicinspection.federalregister.gov/2012-19079.pdf
)
This is the vehicle for rulemaking on the specifics of the ASC quality reporting program; ASC information begins on page
1534 ; Section E.
◦
Participation in the ASC Quality Reporting Program; Page 1540
◦
Limited details for public reporting of data; Page 1541
◦
Data completeness and validation; Page 1548
◦
Extraordinary circumstances; Page 1554
◦
Reconsideration and appeals process; Page 1558



Once an ASC submits any quality measure data, the center would be considered participating
The ASC will continue to be considered a participant, regardless of whether the ASC continues to submit quality measure data, until formally withdrawing from the program



An ASC that wishes to withdraw from the ASC Quality Reporting
(ASCQR) Program must fill out an online withdrawal form:
• Located on the QualityNet website www.qualitynet.org
• Click on left hand side: how to participate then
• Click on left hand side: how to withdraw
An ASC can withdraw at any time up to August 31 prior to the payment determination year
An ASC that withdraws will incur a 2% reduction in its Annual
Payment Update (APU) and any subsequent year the ASC is not participating






Process was established in the FY 2013 IPPS/LTCH PPS final rule (77 FR 53642 through 53643)
CMS may grant a waiver or extension to ASCs for data submission requirements if it is determined that a systemic problem with a data collection system directly or indirectly affects the ability to enter data
Needs to be submitted within 45 days of the extraordinary circumstance
Form (Extraordinary Circumstances) is located on www.qualitynet.org
; click on ASC tab; form is located on the left side of the page
In the future this process will be referred to as the
Extraordinary Circumstances Extensions or Exemptions
Process





Process was established in the FY 2013 IPPS/LTCH PPS final rule (77 FR 53643 through 53644)
Reconsideration request form must be submitted by
March 17 of the affected payment year
CMS intends to complete any reconsideration reviews and communicate results within 90 days following the deadline (March 17 of the affected payment year)
Form (Annual Payment Update (APU) reconsideration) is located on www.qualitynet.org
; click on ASC tab; form is located on the left side of the page








Procedure Category Corresponding
HCPCS Codes:
Eye/Gastrointestinal/Genitourinary/Musculoskeletal/
Nervous/Respiratory/Skin/Multi-system}

Safe Surgery Checklist Use
 Intent: Assess whether an ASC uses a safe surgery checklist


May employ any checklist as long as it addresses effective communication and safe surgery practices in each of three peri-operative periods:
• the period prior to the administration of anesthesia,
• the period prior to skin incision, and
• the period of closure of incision and prior to the patient leaving the operating room
Applies to all ASCs



,


ASC Volume of Selected Procedures
 Intent: Measure all patient volume of procedures performed in one of eight categories
• Eye
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Nervous System
• Respiratory
• Skin
• Multi-system


Measurement from January 1, 2014 through December 31, 2014
Report volumes for entire 2014 calendar year on the QualityNet web site ( www.qualitynet.org
) between January 1 thru August 15,
2015

Organ System
Eye
Gastrointestinal
CMS Procedure Category
Organ transplant (eye)
Laser procedure of eye
Glaucoma procedures
Cataract procedures
Injection of eye
Retina, macular and posterior segment procedures
Repair of surrounding eye structures
GI endoscopy procedures
Swallowing tube (esophagus)
Hernia repair
GI screening procedures
Surgical Procedure Codes
65756, V2785
65855, 66761, 66821
66170, 66180 , 66711
66982, 66984
67028, J2778, J3300, J3396
67041, 67042, 67210, 67228
15823, 67900, 67904, 67917, 67924
43239, 43235, 43248, 43249, 43251,
44361, 45330, 45331, 45378, 45380,
45381, 45383, 45384, 45385 , 46221
43450
49505
G0105, G0121

Organ System
Genitourinary
Musculoskeletal
CMS Procedure Category
Kidney stone fragmentation
Bladder related procedures
Prostate biopsy
Radiologic procedures (GU)
Ultrasound procedures (GU)
Joint or muscle aspiration or injection
Removal of musculoskeletal implants
Repair of tendons and ligaments
Repair of foot, toes, fingers, and wrist
Removal of musculoskeletal lesion
Joint arthroscopy
Musculoskeletal drug injection
Surgical Procedure Codes
50590
52000, 52005, 52204, 52281,
52310, 52332
55700
74420
76872
20610
20680
23412
26055, 28270, 28285, 28296,
29848
26160
29824, 29826, 29827, 29880,
29881 , 29823, 29822
J0585, J0878, J0131

Organ System
Nervous
Respiratory
CMS Procedure Category
Injection procedures in or around the spine
Device implant
Nerve decompression
Repair of foot, toes, fingers, and wrist
Sinus procedure
Surgical Procedure Codes
62310, 62311, 64479, 64480,
64483, 64484, 64490, 64491,
64492, 64493, 64494, 64495,
64622, 64623, 64626, 64627,
64633, 64634, 64635, 64636,
64640, G0260 , J2278
63650
64718
64721
30140, 31255, 31267
Skin
Multi-system*
Skin procedures including debridement, reconstructive, wound closure, excision and/or repair
11042, 13132, 14040, 14060,
15260, 17311, Q4101, Q4102,
Q4106
Brachytherapy
Cancer treatment with angiogenesis inhibitor
*Multi-System: procedures that can be performed in more than one organ system.
C2638, C2639, C2640, C2641
C9257




Claims Based Reporting–Quality Data Codes (QDCs)
• Patient Burn
• Patient Fall
•
Wrong Site, Side, Patient, Procedure, Implant
• Hospital Admission/Transfer
• Prophylactic IV Antibiotic Timing
Web Based Reporting via QualityNet Secure Portal
( www.qualitynet.org
)
• Safe Surgery Check List Use
• ASC Volume of Selected Procedures for all-patients
Web Based Reporting Via Centers for Disease Control and Prevention (CDC) National Health Care Safety
Network (NHSN) ( www.cdc.gov/nhsn/index.html
)
•
Influenza Vaccination Coverage Among Health Care Personnel


Web Based Reporting via QualityNet Secure
Portal ( www.qualitynet.org
)
• Safe Surgery Check List Use
• ASC Volume of Selected Procedures for all-patients
 No reporting for these two measures for 2013
 Data Collection for these two measures will resume January 1 - December 31, 2014
 Data Reporting for calendar year 2014 will be from January 1- August 15, 2015









ASC Program Measurement Set for the CY 2016 Payment Determination
ASC-1: Patient Burn
ASC-2: Patient Fall
ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure,
Wrong Implant
ASC-4: Hospital Transfer/Admission
ASC-5: Prophylactic Intravenous (IV) Antibiotic Timing
ASC-6: Safe Surgery Checklist Use
ASC-7: ASC Facility Volume Data on Selected ASC Surgical Procedures
{ Procedure Category Corresponding HCPCS Codes:
Eye/Gastrointestinal/Genitourinary/Musculoskeletal/
Nervous/Respiratory/Skin/Multi-system}
ASC- 8: Influenza Vaccination Coverage among Healthcare Personnel *
*New measure for CY 2016 payment determination

 Intent: assess the percentage of HCP immunized for influenza during the flu season
 3 Categories of Healthcare Personnel will include:
• Employee on facility payroll
• Licensed independent practitioners, e.g. physicians (MDs, DO), advance practice nurses and physician assistants who are affiliated with the facility who do not receive a direct paycheck from the facility
• Adult students/trainees and volunteers who do not receive a direct paycheck from the facility





Data collection begins with immunizations for the flu season October 1, 2014 through March 31, 2015
CDC’s NHSN website for enrollment: www.cdc.gov/nhsn/ambulatory-surgery/enroll.html
◦
“NHSN facility administrator enrollment guide” (step by step)
Deadline for data submission for the 2014-2015 flu season through May 15, 2015.








Users must fax or mail notarized proof of identity to
CDC.
You will receive a grid card in the mail in order to access NHSN.
Complete and submit required forms (facility information, facility survey, consent form)
 Reporting ( https://sams.cdc.gov
) user authorization through Secure Access Management Services (SAMS) is required for access to NHSN.

1. Number of HCP who worked at this healthcare facility for at least 1 day between October 1 and March 31
2. Number of HCP who received an influenza vaccination at this healthcare facility since influenza vaccine became available this season
3. Number of HCP who provided a written report or documentation of influenza vaccination outside this healthcare facility since influenza vaccine became available this season
4. Number of HCP who have a medical contraindication to the influenza vaccine
5. Number of HCP who declined to receive the influenza vaccine
6. Number of HCP with unknown vaccination status (or criteria not met for questions 2-5 above
Employee HCP
Employees (staff on facility payroll)
Licensed independent practitioners:
Physicians, advanced practice nurses, & physician assistants
Non-Employee HCP
Adult students/ trainees & volunteers
Other contract personnel

 Employee HCP


Non-Employee HCP: Licensed independent practitioners (physicians, advance practice nurses, and physician assistants)
Non-Employee HCP: Adult students/trainees and volunteers
41





Influenza vaccinations
◦
Received at this healthcare facility
◦
Received elsewhere
Medical contraindications
Declinations
Unknown status

 10 + 20 + 15 + 5 + 5 = 55
 70 + 10 + 10 + 5 + 5 = 100
 20 + 2 + 1 + 1 + 1 = 25




Claims Based Reporting–Quality Data Codes (QDCs)
• Patient Burn
• Patient Fall
•
Wrong Site, Side, Patient, Procedure, Implant
• Hospital Admission/Transfer
• Prophylactic IV Antibiotic Timing
Web Based Reporting via QualityNet Secure Portal
( www.qualitynet.org
)
• Safe Surgery Check List Use
• ASC Volume of Selected Procedures for all-patients
Web Based Reporting Via Centers for Disease Control and Prevention (CDC) National Health Care Safety
Network (NHSN) ( www.cdc.gov/nhsn/index.html
)
•
Influenza Vaccination Coverage Among Health Care Personnel




The CDC conducted live training webinars in August to cover the requirements for collecting and entering HCP influenza vaccination summary data.
A recording of the webinar has been posted at: http://www2.cdc.gov/vaccines/ed/nhsn/ , so staff can review the recorded training and slides.
For questions on HCP influenza vaccination summary reporting, please send an e-mail to:
NHSN@cdc.gov
and include “HPS Flu Summary-ASC” in the subject line.

 Released on November 27, 2013
 www.gpo.gov/fdsys/pkg/FR-2013-12-10/pdf/2013-
28737.pdf
• ASC Quality Reporting Program begins on page 974 ;
Section XV. Requirements for ASC Quality Reporting
Program
• 3 Quality Measures for CY 2016: page 979
• 50% minimum reporting threshold: page 1025
• Exempting low volume providers: page 1027
(less than 240 Medicare claims/year)



Previous ASC 1- ASC 8 plus
3 Additional Measures:
• Endoscopy/Poly Surveillance: Appropriate follow-up interval for normal colonoscopy in average risk patients (NQF
#0658);
• Endoscopy/Poly Surveillance: Colonoscopy Interval for
Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use (NQF #0659); and
• Cataracts: Improvement in Patient’s Visual Function within
90 Days Following Cataract Surgery (NQF #1536).
* NQF= National Quality Forum ( www.qualityforum.org
)



Denominator: patients aged 50 years and older receiving screening colonoscopy without biopsy or polypectomy
Numerator: patients who had a recommended follow- up interval of 10 years for repeat colonoscopy documented in their colonoscopy report*
*follow-up interval is at least 10 years from the date of the current colonoscopy
*physician’s documentation in the colonoscopy report

 Exclusions: documentation of medical reasons for not recommending at least a 10-year follow-up (above average risk, inadequate prep)
 Inclusions:
Patients aged ≥ 50 on date of encounter
And
ICD-9-CM Diagnosis code: V76.51
And
CPT or HCPCS: 45378, G0121
Without
CPT Category I Modifiers: 52, 53, 73, 74
Without
ICD-9-CM Diagnosis codes: V18.51, V12.72, V16.0, V10.05
(The ICD-9 codes will be updated when the conversion to ICD-10 occurs)

 Denominator: number of patients 18 years and older receiving a surveillance colonoscopy with a history of a prior colonic polyp in a previous colonoscopy
 Numerator: number of patients who had an interval of three or more years since their last colonoscopy*
*Information regarding performance interval can be obtained from the medical record.


• Documentation of medical reason(s) for an interval of less than three years since the last colonoscopy (for example, last colonoscopy incomplete, last colonoscopy had inadequate prep, piecemeal removal of adenomas, or last colonoscopy found greater than
10 adenomas)
• Documentation of a system reason(s) for an interval less than three years since last colonoscopy (for example, unable to locate previous colonoscopy report, previous colonoscopy report was incomplete)


Patients aged ≥ 18 years on date of encounter
And
Diagnosis for history of colonic polyp(s) (ICD-9-CM): V12.72,
V10.05
And
CPT or HCPCS: 44388, 44389, 44392, 44393, 44394, 45355,
45378, 45380, 45381, 45383, 45384, 45385, G0105
Without
CPT Category I Modifiers: 52, 53, 73 or 74
(The ICD-9 codes will be updated when the conversion to ICD-10 occurs)

 Denominator: number of patients aged 18 years and older in sample who had cataract surgery and completed both a pre-operative and post-operative visual function instrument
 Numerator: number of patients 18 years and older who had improvement in visual function achieved within 90 days following cataract surgery, based on completing both a pre-operative and post-operative visual function instrument

Examples of tools for visual function assessment include, but are not limited to:
 National Eye Institute-Visual Function Questionnaire – VFQ-25 www.rand.org/health/surveys_tools/vfq.html
 Visual Function (VF)-14 www.med.teikyo-u.ac.jp/~ortho/med/reh/VF-14.html
 Modified VF-8 http://ascrs.org/sites/default/files/resources/2013%20Cataracts%20Measure s%20Group%20Post-Surgery%20VF-8R_0.pdf
 Modified Catquest-9 http://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/OPX/
A/
OPX_90_8_2013_04_04_LUNDSTROM_201940_SDC1.pdf

55

Population Per Year 0-900
Yearly Sample Size 63
Quarterly Sample Size 16
Monthly Sample Size 6
Population Per Year ≥901
Yearly Sample Size 96
Quarterly Sample Size 24
Monthly Sample Size 8





Claims Based Reporting–Quality Data Codes (QDCs)
•
Patient Burn
• Patient Fall
•
Wrong Site, Side, Patient, Procedure, Implant
• Hospital Admission/Transfer
•
Prophylactic IV Antibiotic Timing
Web Based Reporting via QualityNet Secure Portal ( www.qualitynet.org
)
• Safe Surgery Check List Use
•
ASC Volume of Selected Procedures for all-patients
Web Based Reporting Via Centers for Disease Control and Prevention (CDC)
National Health Care Safety Network (NHSN)
( www.cdc.gov/nhsn/index.html
)
•
Influenza Vaccination Coverage Among Health Care Personnel
Web Based Reporting via QualityNet Secure Portal ( www.qualitynet.org
)
• Endoscopy/Polyp Surveillance (normal)
•
Endoscopy/Polyp Surveillance (adenomatous)
• Cataract: improvement in visual functionvoluntary

 Released on October 31, 2014
• http://www.ofr.gov/(S(j4muxl5s4vqongwcshdlh533))/O
FRUpload/OFRData/2014-26146_PI.pdf
• ASC Quality Reporting Program begins on page 781 :
Section XIV. Requirements for ASC Quality Reporting
Program

 Previous ASC 1- ASC 10 plus
 ASC 11: Cataracts: Improvement in Patient’s Visual
Function within 90 Days Following Cataract Surgery (NQF
#1536) voluntary
NQF = National Quality Forum ( www.qualityforum.org
)

 Previous ASC 1- ASC 10 plus


ASC 11: Cataracts: Improvement in Patient’s Visual
Function within 90 Days Following Cataract Surgery (NQF
#1536) voluntary
1 Additional Measure:
ASC 12: Facility Seven-Day Risk-Standardized Hospital
Visit Rate after Outpatient Colonoscopy
NQF = National Quality Forum ( www.qualityforum.org
)

 Claims based measure
 No additional data submission from ASCs
 The measure outcome is all unplanned hospital visits (admissions, observation stays, and emergency department [ED] visits) within 7 days of the procedure.




In 2015, Medicare will perform a “dry run” of this measure.
A dry run is a preliminary analysis of data in which ASCs may review their measure results, and ask questions about and become familiar with the measure methodology.
The most recent complete claims samples
(usually 6-9 months prior to the start date) for dry runs will be used.





The dry run will generate confidential reports at the patient level, indicating whether the patient had a hospital visit, the type of visit (admission, ER visit, or observational stay), the admitting facility, and the principal discharge diagnosis.
The ASC will have the opportunity to receive individual patient data and information contained within individual patient records in order to identify performance gaps and develop quality improvement strategies.
Dry runs results ARE NOT linked to public reporting or payment determinations.
ASCs can review their confidential dry run reports at www.qualitynet.org
.

 For the CY 2018 payment determination, paid
Medicare Fee For Service claims from January 1 –
December 31, 2016 will be used (calendar years
2 years before the payment determination calendar year.






Patient experience of care: ASC Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient experience survey
Care Plan- (percentage of patients 65 years and older who have a care plan or surrogate decision documented in the medical record)
Hair removal
Normothermia
Unplanned anterior vitrectomy

 ASC Quality Collaboration website (measure summary and implementation guide) http://ascquality.org/qualitymeasures.cfm
 Ambulatory Surgery Center Association (ASCA) http://www.ascassociation.org
 QualityNet website
(CMS Specifications Manual & Email Notifications) http://qualitynet.org
 FMQAI website (CMS national support contractor) http://oqrsupport.org
 CMS certification number (CCN) Look-Up Tool (allows a facility to enter its
National Provider Identifier (NPI) in the search box to find its CCN) http://www.oqrsupport.com/asc/ccn

Contact FMQAI for Program Questions at oqrsupport@sdps.com
or via phone (866) 800-8756
Monday through Friday,
7 a.m. to 6 p.m. Eastern Time
Contact the QualityNet Help Desk for Technical Issues at qnetsupport@sdps.org
or via phone (866) 288-8912
Monday through Friday,
7 a.m. to 7 p.m. Central Time

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Federal Register / Vol. 76, No. 230 / Wednesday, November 30, 2011 / Rules and Regulations.
Available at http://www.gpo.gov/fdsys/pkg/FR-2011-11-30/pdf/2011-28612.pdf
Federal Register / Vol. 77, No. 170 / Friday, August 31, 2012/ Rules and Regulations. Available at http://www.gpo.gov/fdsys/pkg/FR-2012-08-31/pdf/2012-19079.pdf
Federal Register / Vol. 77, No. 221 / Thursday, November 15, 2012 / Rules and Regulations. Available at http://www.gpo.gov/fdsys/pkg/FR-2012-11-15/pdf/2012-26902.pdf
Federal Register / Vol. 78, No. 237 / Tuesday, December 10, 2013/ Rules and Regulations. Available at http://www.gpo.gov/fdsys/pkg/FR-2013-12-10/pdf/2013-28737.pdf
Federal Register / Vol. 79, No. 134 / Monday, July 14, 2014/ Rules and Regulations. Available at http://www.gpo.gov/fdsys/pkg/FR-2014-07-14/pdf/2014-15939.pdf
ASC Quality Collaboration Implementation Guide, Version 2.1, April 2014. Available at http://ascquality.org/documents/ASCQC.Implementation.Guide.2.1April2014.pdf
CMS ASC Quality Reporting Program Quality Measures Specifications Manual, Version 4.0, June 2014.
Available at www.qualitynet.org
Quality Net at www.qualitynet.org
National Healthcare Safety Network www.cdc.gov/nhsn/ http://www.ofr.gov/(S(j4muxl5s4vqongwcshdlh533))/OFRUpload/OFRData/2014-26146_PI.pdf

Gina Throneberry, RN, MBA, CASC, CNOR
Ambulatory Surgery Center Association (ASCA)
Director or Education and Clinical Affairs gthroneberry@ascassociation.org