CMS Quality Reporting for ASCs
Gina Throneberry, RN, MBA, CASC, CNOR
Director of Education and Clinical Affairs
Ambulatory Surgery Center Association (ASCA)
Learning Objectives
• Participants will:
• Identify quality reporting by Centers for Medicare
& Medicaid Services (CMS) for Ambulatory
Surgery Centers (ASCs)
• Understand the history of quality measure
development
• Collect and report the data for the required
quality measures
General FAQs about the CMS ASC
Quality Reporting Program
• I would like clarification on the definition of an Ambulatory
Surgical Center (ASC) as it relates to the requirements for the ASC
Quality Reporting Program. My understanding is that only freestanding ASCs that are billing with their own CCN would be
required to submit under that program. Is this correct?
You are correct. ASCs have their own ASC numbers - an
alphanumeric code where the third digit is the letter "C" - and bill
using their own system.
An ASC that is part of a hospital's regional outpatient facility that is
billing under the hospital's CCN would not be included.
The ambulatory surgery cases billed under the hospital's CCN would
be eligible for inclusion in the relevant measures in the Hospital
Outpatient Quality Reporting (OQR) Program. *
*Per www.qualitynet.org
General FAQs about the CMS ASC
Quality Reporting Program
• What is a CCN, and where can I locate it?
A Center for Medicare and Medicaid Services (CMS)
Certification Number, or CCN, is established by CMS
for each facility and designates the facility as a CMScertified, free standing ASC. Your billing department
should serve as a good resource for locating this
number. An ASC CCN is an alphanumeric 10 digit
number - the first two digits represent the state's
number, and the following letter is a "C." For
example, an ASC in Florida would have a CCN that
looks like "10C000xxxx.“ *
*Per www.qualitynet.org
ASCQR Program Rule History
Rule
Reference
Proposed
or Final
Rule
Federal Register (FR) Reference
https://www.federalregister.gov
Program Highlights
CY 2014
OPPS/ASC
Final
78 FR 75122
Finalized 3 measures
CY 2013
OPPS/ASC
Final
77 FR 68492
No additional measures
FY 2013
IPPS/LTCH PPS
Final
77 FR 53637
Finalized requirements
CY 2012
OPPS/ASC
Final
76 FR 74492
Finalized 8 measures
CY 2011
OPPS/ASC
Final
75 FR 72109
Discussed/Not
implemented
CY 2010
OPPS/ASC
Final
74 FR 60656
Discussed/Not
implemented
CY 2009
OPPS/ASC
Final
73 FR 68780
Discussed/Not
implemented
CY 2008
OPPS/ASC
Final
72 FR 66875
Discussed/Not
implemented
2012 HOPD/ASC Final Rule (CMS
1525FC) Quality Reporting Program
 On November 1, 2011, Medicare released the calendar year
(CY) 2012 Medicare Hospital Outpatient Prospective Payment
System (OPPS)/ ASC Payment final rule (1552 pages)
 The ASC Quality Reporting Program was implemented
beginning with the CY 2014 payment determination, data
collection began in CY 2012 for some of the measures
 Pay for Reporting; Not Pay for Performance at this time
 ASCs that fail to successfully report will face a 2% facility fee
reduction in future year’s rates.
ASCQR Program Measures Summary
Number
ASC-1
ASC-2
ASC-3
ASC-4
ASC-5
ASC-6
ASC-7
ASC-8
ASC-9
ASC-10
ASC-11
Measure Title
Type of Measure
Initial Encounter/
Reporting Date
Patients
October 1, 2012
October 1, 2012
October 1, 2012
Initial Payment
Determination
Year
CY 2014
CY 2014
CY 2014
Patient Burn
Patient Fall
Wrong Site, Wrong Side, Wrong
Patient, Wrong Procedure,Wrong
Implant
Hospital Transfer/Admission
Prophylactic Intravenous (IV)
Antibiotic Timing
Safe Surgery Checklist Use
Claims-Based
Claims-Based
Claims-Based
Claims-Based
Claims-Based
October 1, 2012
October 1, 2012
CY 2014
CY 2014
Medicare
Medicare
Web-Based
CY 2012
July – August 2013
CY 2012
July – August 2013
Entry TBD;
October 2014 – March
2015
CY 2014
January 1 – August 15,
2015
CY 2015
All
ASC Facility Volume Data on
Selected ASC Surgical Procedures
Influenza Vaccination Coverage
among Healthcare Personnel
Web-Based
CY 2015
All
CY 2016
Health Care
Personnel
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
Web-Based
CY 2016
Sampling
Web-Based
CY 2014
January 1 – August 15,
2015
CY 2016
Sampling
Web-Based
CY 2014
January 1 – August 15,
2015
CY 2016
Sampling
Web-Based
via NHSN
Medicare
Medicare
Medicare
ASC Quality Collaboration, Inc.
Measures Implementation Guide
www.ascquality.org
CMS Ambulatory Surgical Center
Quality Reporting Program
• CMS ASC Quality Reporting Program Quality
Measures Specifications Manual
• To date- 6 versions (April 2012-December 2013)
• Latest version- 3.0a (December 2013)
• Located @ www.qualitynet.org under ASC tab
• Included in this manual:
• Measure specifications
• Data collection and submission
• Quality Data Codes (QDCs)
Measures for ASCs
ASC Program Measurement Set for the CY 2014
and 2015 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*
*Data submission began in CY 2012
How Will the Data be Reported?
• 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 Quality Net
(www.qualitynet.org)
• Safe Surgery Check List Use
• ASC Volume of Selected Procedures for all-patients
• Web Based Reporting Via Center for Disease Control’s
(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
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.
Patient burn
G8908 Patient documented to have received a burn prior to discharge
G8909 Patient documented not to have received a burn prior to discharge
Patient fall in ASC facility
G8910 Patient documented to have experienced a fall within ASC
Patient documented not to have experienced a fall within Ambulatory Surgical
G8911 Center
Wrong site, wrong side, wrong
patient, wrong procedure, wrong
Patient documented to have experienced a wrong site, wrong side, wrong patient,
implant
G8912 wrong procedure or wrong implant event
Patient documented not to have experienced a wrong site, wrong side, wrong
G8913 patient, wrong procedure or wrong implant event
Patient documented to have experienced a hospital transfer or hospital admission
Hospital transfer/Admission
G8914 upon discharge from ASC
Patient documented not to have experienced a hospital transfer or hospital
G8915 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
General FAQs about the CMS ASC
Quality Reporting Program
• Do we need to include Pre-Admission Testing (PAT)
visits conducted in an ASC for the ASCQR Program?
A visit for PAT is not considered an ASC admission
for purposes of the ASCQR Program.*
• Can we submit claims to correct G codes?
Do not re-submit a claim only for the purpose of
correcting or adding G-codes. Resubmission of
claims should occur only to collect the payment from
the original date of service. *
*Per www.qualitynet.org
General FAQs about the CMS ASC
Quality Reporting Program
• If a patient is admitted to the ASC, but the case is
cancelled before any procedure is performed,
does quality measure data need to be reported
for this case?
If the ASC submits a claim for Medicare
reimbursement for this case, then the appropriate
QDCs should be reported as this claim will be
included in the completeness of reporting
calculation.*
*Per www.qualitynet.org
Inpatient/Long Term Care Hospital
Prospective Payment System (IPPS)
Final Rule
• 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:
• Data completeness and validation
• Reconsideration and appeals process
• Limited details for public reporting of data
Additional Quality Reporting Info from
the IPPS* Final Rule (July 2012)
• ASC information begins on page 1534; Section E.
Proposed Quality Reporting Requirements for
Ambulatory Surgical Centers (ASCs)
• Participation in the CMS ASC Quality Reporting
Program. Page 1540
• Publicly reporting quality data. Page 1541.
*Inpatient Prospective Payment Systems
Additional Quality Reporting Info from
the IPPS* Final Rule (July 2012)
• The completeness threshold is set at 50%. Page 1548
• ASCs will be considered successful reporters and
get their full payment if 50% of the relevant claims
contain the quality data codes (2012 and 2013).
• There is a process for an extension in extraordinary
circumstances. Page 1554.
• The reconsideration and appeals process is based on
the one the hospital uses now. Page 1558.
*Inpatient Prospective Payment Systems
Participation and Non Participation
• Once an ASC submits any quality measure data, the
center would be considered participating
• To receive the full annual payment update (APU), an
ASC must meet all program requirements:
• submits quality measure data (i.e., Quality Data Codes
[QDCs]) on the CMS Form 1500
• submits web-based measure data
• 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.
• For ASCs participating in the program, quality measure
data submitted could be made publicly available.
Participation and Non Participation
• 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.
Extraordinary Circumstances
Extension/ Waiver Process
• 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
Reconsideration 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
Measures for ASCs
ASC Program Measurement Set for the CY 2015
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}
*New measures for CY 2015 payment determination; Data
collection began CY 2012
Measure Details
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:
• prior to administering anesthesia,
• prior to incision, and
• prior to the patient leaving the operating room
• Applies to all ASCs
Measure Details
Safe Surgery Checklist Use
• For 2014 and beyond, the checklist should be
utilized for the ENTIRE year for an answer of
"Yes".
• Report “Yes” or “No” on the Quality Net web
site (www.qualitynet.org) between January 1
through August 15, 2015.
Measure Details
Safe Surgery Checklist Resources
• World Health Organization (WHO)
• http://www.who.int/patientsafety/safesurgery/ss_checklist/en/
• SafeSurg.org:
•
•
For a modifiable template: http://www.safesurg.org/templatechecklist.html
For examples, including for endoscopy centers:
http://www.safesurg.org/modified-checklists.html
• AORN (combines WHO checklist and JC universal
protocol)
• http://www.aorn.org/PracticeResources/ToolKits/CorrectSiteSurgeryToolKi
t/Comprehensivechecklist/
Measure Details
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
Measure Details
• The specifications manual version 3.0a
released in December 2013 contains a new
table of HCPCS or CPT codes.
• This revision was based on claims data from
2012, the top 100 procedures (based on
volume) were determined, and the
corresponding codes were used to update the
table within the measure.
Organ System
CMS Procedure Category
Surgical Procedure Codes
Eye
Organ transplant (eye)
65756, V2785
Laser procedure of eye
65855, 66761, 66821
Glaucoma procedures
66170, 66180 , 66711
Cataract procedures
66982, 66984
Injection of eye
67028, J2778, J3300, J3396
Retina, macular and posterior segment procedures
67041, 67042, 67210, 67228
Repair of surrounding eye structures
15823, 67900, 67904, 67917, 67924
GI endoscopy procedures
43239, 43235, 43248, 43249, 43251,
44361, 45330, 45331, 45378, 45380,
45381, 45383, 45384, 45385 ,46221
Swallowing tube (esophagus)
43450
Hernia repair
49505
GI screening procedures
G0105, G0121
Gastrointestinal
Organ System
CMS Procedure Category
Surgical Procedure Codes
Genitourinary
Kidney stone fragmentation
50590
Bladder related procedures
52000, 52005, 52204, 52281,
52310, 52332
Prostate biopsy
55700
Radiologic procedures (GU)
74420
Ultrasound procedures (GU)
76872
Joint or muscle aspiration or injection
20610
Removal of musculoskeletal implants
20680
Repair of tendons and ligaments
23412
Repair of foot, toes, fingers, and wrist
26055, 28270, 28285, 28296,
29848
Removal of musculoskeletal lesion
26160
Joint arthroscopy
29824, 29826, 29827, 29880,
29881 , 29823, 29822
Musculoskeletal drug injection
J0585, J0878, J0131
Musculoskeletal
Organ System
CMS Procedure Category
Surgical Procedure Codes
Nervous
Injection procedures in or around the spine
62310, 62311, 64479, 64480,
64483, 64484, 64490, 64491,
64492, 64493, 64494, 64495,
64622, 64623, 64626, 64627,
64633, 64634, 64635, 64636,
64640, G0260 , J2278
Device implant
63650
Nerve decompression
64718
Repair of foot, toes, fingers, and wrist
64721
Respiratory
Sinus procedure
30140, 31255, 31267
Skin
Skin procedures including debridement,
reconstructive, wound closure, excision and/or
repair
11042, 13132, 14040, 14060,
15260, 17311, Q4101, Q4102,
Q4106
Multi-system*
Brachytherapy
Cancer treatment with angiogenesis inhibitor
C2638, C2639, C2640, C2641
C9257
*Multi-System: procedures that can be performed in
more than one organ system.
How Will the Data be Reported?
• 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 Quality Net
(www.qualitynet.org)
• Safe Surgery Check List Use
• ASC Volume of Selected Procedures for all-patients
• Web Based Reporting Via Center for Disease Control’s
(CDC)
National Health Care Safety Network (NHSN)
(www.cdc.gov/nhsn/index.html)
• Influenza Vaccination Coverage Among Health Care Personnel
How Will the Data be Reported?
• Web Based Reporting via Quality Net
(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
Requirements for QualityNet
Account and Administrator
• A QualityNet account is required to submit quality
data to the QualityNet Web site
• ASCs will need to identify and register a QualityNet
administrator who follows the registration process
located on the QualityNet Web site
• Allow 6 weeks for the security administrator process
to be completed
• QualityNet accounts are automatically deactivated
after a 120-day period of inactivity in accordance
with CMS security policy.
QualityNet Home Page
www.qualitynet.org
QualityNet Home Page
ASC Registration is located in a blue box
on the left hand side of the home page
QualityNet ASC Registration
Additional Requirements for
QualityNet Account and Administrator
• As of May 31, 2013, the Centers for Medicare & Medicaid
Services (CMS) is now requiring QualityNet users for the ASC
Quality Reporting Program complete an additional user
enrollment process to ensure access to the Secure QualityNet
Portal.
• After receiving a user ID and password, the security
administrator will now be required to download the Symantec
VIP Access application (Symantec VIP multifactor credential
application).
• When logging in to the portal for the first time, security
administrators will be guided through a six‐step New User
Enrollment Process that includes personal identity verification
conducted by Experian, an external service enlisted by CMS.
Secure QualityNet Portal Log In
QualityNet
Portal Log-in
QualityNet Portal Registration
Start/Complete
New User
Enrollment
Quick Link to VIP
Access App
QualityNet Secure Portal
Measures for ASCs
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
Measure Details
Influenza Vaccination Coverage among
Healthcare Personnel (HCP)
• Intent: assess the percentage of HCP immunized for influenza
during the flu season
• Center for Disease Control (CDC) in the process of revising
measure specifications for ASCs
• 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
Influenza Vaccination Coverage
Among Healthcare Personnel (HCP)
• Measurement begins with immunizations for
the flu season October 1, 2014 through March
31, 2015
• CDC’s NHSN website for enrollment:
• www.cdc.gov/nhsn/ambulatorysurgery/enroll.html
• Deadline for ASC submission will be finalized
with the final rule for CY 2015
Enrollment Steps
• Review and accept the NHSN rules of
behavior
• Register with SAMS
• SAMS = Secure Access Management
Services, a federal information technology
(IT) system that gives authorized personnel
secure access to non-public CDC
applications
SAMS
• Users must fax or mail notarized proof of
identity to CDC.
• This is not a background check – this information
will only be used to verify your identity and will
not be shared outside of NHSN
• 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 to NHSN
• Report to CDC’s National Healthcare Safety
Network (NHSN):
www.cdc.gov/nhsn/index.html October 1,
2014 through March 31, 2015
• Enter data for all numerator and denominator
categories
Influenza Vaccination Summary
Employee HCP
Non-Employee HCP
Employees (staff Licensed independent
on facility payroll)
practitioners:
Physicians, advanced
practice nurses, &
physician assistants
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
Adult students/
trainees &
volunteers
Other contract
personnel
Denominator Categories
• Employee HCP
• Non-Employee HCP: Licensed independent
practitioners (physicians, advance practice nurses,
and physician assistants)
• Non-Employee HCP: Adult students/trainees and
volunteers
48
Numerator Categories
• Influenza
vaccinations
– Received at this
healthcare facility
– Received elsewhere
• Medical
contraindications
• Declinations
• Unknown status
Notes on Reporting – Example
 10 + 20 + 15 + 5 + 5 = 55
 70 + 10 + 10 + 5 + 5 = 100
 20 + 2 + 1 + 1 + 1 = 25
How Will the Data be Reported?
• 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 Quality Net
(www.qualitynet.org)
• Safe Surgery Check List Use
• ASC Volume of Selected Procedures for all-patients
• Web Based Reporting Via Center for Disease Control’s
(CDC)
National Health Care Safety Network (NHSN)
(www.cdc.gov/nhsn/index.html)
• Influenza Vaccination Coverage Among Health Care Personnel
2013 Medicare Hospital Outpatient
Prospective Payment System (OPPS)/ASC
Payment Final Rule
• Released on November 1, 2012
• http://www.gpo.gov/fdsys/pkg/FR-2012-1115/pdf/2012-26902.pdf (page 979-1010/1249)
• No new measures proposed
2014 Medicare Hospital Outpatient
Prospective Payment System (OPPS)/ASC
Payment Final Rule
• Released on November 27, 2013
• www.gpo.gov/fdsys/pkg/FR-2013-12-10/pdf/201328737.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)
New ASC Measures for CY 2016 and
Subsequent Payment Determination Years
• 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)
Endoscopy/Polyp Surveillance:
Normal Colonoscopy
• 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
Endoscopy/Polyp Surveillance:
Normal Colonoscopy
• 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: V13.89, V18.51, V12.72, V16.0, V10.05
(In October 2014 the ICD-9 codes will be updated to ICD-10)
Endoscopy/Polyp Surveillance:
Adenomatous Polyp
• 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.
Endoscopy/Polyp Surveillance:
Adenomatous Polyp
• Exclusions:
• 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)
Endoscopy/Polyp Surveillance:
Adenomatous Polyp
• Inclusions:
Patients aged ≥ 18 years on date of encounter
And
Diagnosis for history of colonic polyp(s) (ICD-9-CM): V12.72,
V13.89, 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
(In October 2014 the ICD-9 codes will be updated to ICD-10)
Cataract: Improvement in Patients
Visual Function within 90 days
• 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
Cataract: Improvement in Patients
Visual Function within 90 days
• Exclusions: Patients who did not complete both a
pre-operative and post-operative survey
• Inclusions: Patients aged ≥18 years
And
CPT (with or without modifiers): 66840, 66850,
66852, 66920, 66930, 66940, 66982, 66983, 66984
Cataract: Improvement in Patients
Visual Function within 90 days
Definition for Survey:
• The data collection instrument is specified as an
assessment tool that has been appropriately
validated for the population for which it is being
used.
• The same data collection instrument used preoperatively should be used post-operatively.
• The surveys can be completed by phone, mail, or
email during physician follow-up.
Cataract: Improvement in Patients
Visual Function within 90 days
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
• Activities of Daily Vision Scale (ADVS)
• Catquest
• Modified Catquest-9
http://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/OPX/
A/OPX_90_8_2013_04_04_LUNDSTROM_201940_SDC1.pdf
Data Collection Tool for Cataract
and Endoscopy Measures
• http://www.oqrsupport.com/asc/tools
Sampling Size Specifications
ASC-9, ASC-10, or ASC-11
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
How Will the Data be Reported?
• 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 Quality Net (www.qualitynet.org)
•
•
Safe Surgery Check List Use
ASC Volume of Selected Procedures for all-patients
• Web Based Reporting Via Center for Disease Control’s (CDC)
National Health Care Safety Network (NHSN)
(www.cdc.gov/nhsn/index.html)
•
Influenza Vaccination Coverage Among Health Care Personnel
• Web Based Reporting via Quality Net (www.qualitynet.org)
• Endoscopy/Polyp Surveillance (normal)
• Endoscopy/Polyp Surveillance (adenomatous)
• Cataract: improvement in visual function
ASCQR Program Measures Summary
Number
ASC-1
ASC-2
ASC-3
ASC-4
ASC-5
ASC-6
ASC-7
ASC-8
ASC-9
ASC-10
ASC-11
Measure Title
Type of Measure
Initial Encounter/
Reporting Date
Patients
October 1, 2012
October 1, 2012
October 1, 2012
Initial Payment
Determination
Year
CY 2014
CY 2014
CY 2014
Patient Burn
Patient Fall
Wrong Site, Wrong Side, Wrong
Patient, Wrong Procedure,Wrong
Implant
Hospital Transfer/Admission
Prophylactic Intravenous (IV)
Antibiotic Timing
Safe Surgery Checklist Use
Claims-Based
Claims-Based
Claims-Based
Claims-Based
Claims-Based
October 1, 2012
October 1, 2012
CY 2014
CY 2014
Medicare
Medicare
Web-Based
CY 2012
July – August 2013
CY 2012
July – August 2013
Entry TBD;
October 2014 – March
2015
CY 2014
January 1 – August 15,
2015
CY 2015
All
ASC Facility Volume Data on
Selected ASC Surgical Procedures
Influenza Vaccination Coverage
among Healthcare Personnel
Web-Based
CY 2015
All
CY 2016
Health Care
Personnel
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
Web-Based
CY 2016
Sampling
Web-Based
CY 2014
January 1 – August 15,
2015
CY 2016
Sampling
Web-Based
CY 2014
January 1 – August 15,
2015
CY 2016
Sampling
Web-Based
via NHSN
Medicare
Medicare
Medicare
General FAQs about the CMS ASC
Quality Reporting Program
• When will ASC Quality Reporting end?
The Ambulatory Surgical Center Quality Reporting
Program is an ongoing program that will continue
to evolve and grow, with new measures being
added periodically.*
*Per www.qualitynet.org
Measures for Future Consideration
•
•
•
•
•
•
•
•
Clinical quality of care
Patient safety
Care coordination
Patient experience of care: ASC Consumer
Assessment of Healthcare Providers and Systems
(CAHPS) patient experience survey
Surgical outcomes
Surgical complications
Complications of anesthesia
Patient-reported outcomes of care
Websites with Additional Information
• 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)
http://qualitynet.org
• FMQAI website (CMS national support contractor)
http://oqrsupport.org
Additional Questions
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
References
 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
 ASC Quality Collaboration Implementation Guide, Version 1.6, October 26, 2011. Available at
http://ascquality.org/documents/ASCQualityCollaborationImplementationGuide.1.6.pdf. Last
accessed July 15, 2013.
 CMS ASC Quality Reporting Program Quality Measures Specifications Manual, Version 3.0a, December
2013. Available at www.qualitynet.org
 Quality Net at www.qualitynet.org
Questions/Comments
Gina Throneberry, RN, MBA, CASC, CNOR
Ambulatory Surgery Center Association (ASCA)
Director or Education and Clinical Affairs
gthroneberry@ascassociation.org