cms quality reporting for ascs

CMS Quality Reporting for ASCs

Gina Throneberry, RN, MBA, CASC, CNORDirector 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 free-standing 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

http://www.qualitynet.org/


• 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 CMS-certified, 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.“ *



ASCQR Program Rule HistoryRule Reference

Proposed or Final

RuleFederal Register (FR) Referencehttps://www.federalregister.gov Program Highlights

CY 2014OPPS/ASC

Final 78 FR 75122 Finalized 3 measures

CY 2013OPPS/ASC

Final 77 FR 68492 No additional measures

FY 2013IPPS/LTCH PPS

Final 77 FR 53637 Finalized requirements

CY 2012OPPS/ASC

Final 76 FR 74492 Finalized 8 measures

CY 2011OPPS/ASC

Final 75 FR 72109 Discussed/Not implemented

CY 2010OPPS/ASC


CY 2009OPPS/ASC


CY 2008OPPS/ASC


https://www.federalregister.gov/

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 SummaryNumber Measure Title Type of Measure Initial Encounter/

Reporting Date Initial Payment Determination

Year

Patients

ASC-1 Patient Burn Claims-Based October 1, 2012 CY 2014 Medicare ASC-2 Patient Fall Claims-Based October 1, 2012 CY 2014 Medicare ASC-3 Wrong Site, Wrong Side, Wrong

Patient, Wrong Procedure,Wrong Implant

Claims-Based October 1, 2012 CY 2014 Medicare

ASC-4 Hospital Transfer/Admission Claims-Based October 1, 2012 CY 2014 Medicare ASC-5 Prophylactic Intravenous (IV)

Antibiotic Timing Claims-Based October 1, 2012 CY 2014 Medicare

ASC-6 Safe Surgery Checklist Use Web-Based CY 2012 July – August 2013

CY 2015 All

ASC-7 ASC Facility Volume Data on Selected ASC Surgical Procedures

Web-Based CY 2012 July – August 2013

CY 2015 All

ASC-8 Influenza Vaccination Coverage among Healthcare Personnel

Web-Based via NHSN

Entry TBD; October 2014 – March

2015

CY 2016 Health Care Personnel

ASC-9 Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients

Web-Based CY 2014 January 1 – August 15,

2015

CY 2016 Sampling

ASC-10 Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use


2015

CY 2016 Sampling

ASC-11 Cataracts – Improvement in Patient’s Visual Function within 90 days Following Cataract Surgery


2015

CY 2016 Sampling

ASC Quality Collaboration, Inc.Measures Implementation Guide

www.ascquality.org

http://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


http://www.cdc.gov/nhsn/index.html

The ASC quality measures, G codes, and their descriptions are included in Table 6 below:ASC Quality Measures G-code Long Descriptor

G8907

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 admission upon discharge from the facility.

Patient burn G8908 Patient documented to have received a burn prior to dischargeG8909 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

G8911Patient documented not to have experienced a fall within Ambulatory Surgical Center

Wrong site, wrong side, wrong patient, wrong procedure, wrong implant G8912

Patient documented to have experienced a wrong site, wrong side, wrong patient, wrong procedure or wrong implant event

G8913Patient documented not to have experienced a wrong site, wrong side, wrong patient, wrong procedure or wrong implant event

Hospital transfer/Admission G8914Patient documented to have experienced a hospital transfer or hospital admission upon discharge from ASC

G8915Patient documented not to have experienced a hospital transfer or hospital admission upon discharge from ASC

Timing of Prophylactic antibiotic administration for SSI prevention G8916

Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis, antibiotic initiated on time

G8917Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis, antibiotic not initiated on time

G8918Patient without preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis


• 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. *




• 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.*



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/public-inspection.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

https://s3.amazonaws.com/public-inspection.federalregister.gov/2012-19079.pdf

https://s3.amazonaws.com/public-inspection.federalregister.gov/2012-19079.pdf

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 ASCsASC 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/template-

checklist.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/

CorrectSiteSurgeryToolKit/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 CodesEye 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

Gastrointestinal 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

Organ System CMS Procedure Category Surgical Procedure CodesGenitourinary Kidney stone fragmentation 50590

Bladder related procedures 52000, 52005, 52204, 52281, 52310, 52332

Prostate biopsy 55700

Radiologic procedures (GU) 74420

Ultrasound procedures (GU) 76872

Musculoskeletal 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

Organ System CMS Procedure Category Surgical Procedure CodesNervous 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

*Multi-System: procedures that can be performed in more than one organ system.

C2638, C2639, C2640, C2641 C9257

How Will the Data be Reported?


• 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 Pagewww.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 ASCsASC 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 DetailsInfluenza 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/ambulatory-surgery/enroll

.html

• Deadline for ASC submission will be finalized with the final rule for CY 2015

http://www.cdc.gov/nhsn/ambulatory-surgery/enroll.html

http://www.cdc.gov/nhsn/ambulatory-surgery/enroll.html

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 on facility payroll)

Licensed independent practitioners:

Physicians, advanced practice nurses, &

physician assistants

Adult students/ trainees & volunteers

Other contract personnel

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

Denominator Categories

48

• Employee HCP • Non-Employee HCP: Licensed independent

practitioners (physicians, advance practice nurses, and physician assistants)

• Non-Employee HCP: Adult students/trainees and volunteers

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

2013 Medicare Hospital Outpatient Prospective Payment System (OPPS)/ASC

Payment Final Rule

• Released on November 1, 2012• http://www.gpo.gov/fdsys/pkg/FR-2012-11-15

/pdf/2012-26902.pdf (page 979-1010/1249)

• No new measures proposed

http://www.gpo.gov/fdsys/pkg/FR-2012-11-15/pdf/2012-26902.pdf


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/2013-28737.pd

f• 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)

http://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 WithoutCPT 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.


• 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)


• Inclusions:Patients aged ≥ 18 years on date of encounter AndDiagnosis for history of colonic polyp(s) (ICD-9-CM): V12.72, V13.89, V10.05 AndCPT 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


• Exclusions: Patients who did not complete both a pre-operative and post-operative survey

• Inclusions: Patients aged ≥18 years AndCPT (with or without modifiers): 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984


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 pre-operatively should be used post-operatively.

• The surveys can be completed by phone, mail, or email during physician follow-up.


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

http://www.rand.org/health/surveys_tools/vfq.html

http://www.med.teikyo-u.ac.jp/~ortho/med/reh/VF-14.html

http://ascrs.org/sites/default/files/resources/2013%20Cataracts%20Measures%20Group%20Post-Surgery%20VF-8R_0.pdf

http://ascrs.org/sites/default/files/resources/2013%20Cataracts%20Measures%20Group%20Post-Surgery%20VF-8R_0.pdf

http://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/OPX/A/OPX_90_8_2013_04_04_LUNDSTROM_201940_SDC1.pdf

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

http://www.oqrsupport.com/asc/tools



Sampling Size SpecificationsASC-9, ASC-10, or ASC-11

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



• 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 SummaryNumber Measure Title Type of Measure Initial Encounter/

Reporting Date Initial Payment Determination

Year

Patients

ASC-1 Patient Burn Claims-Based October 1, 2012 CY 2014 Medicare ASC-2 Patient Fall Claims-Based October 1, 2012 CY 2014 Medicare ASC-3 Wrong Site, Wrong Side, Wrong

Patient, Wrong Procedure,Wrong Implant

Claims-Based October 1, 2012 CY 2014 Medicare

ASC-4 Hospital Transfer/Admission Claims-Based October 1, 2012 CY 2014 Medicare ASC-5 Prophylactic Intravenous (IV)

Antibiotic Timing Claims-Based October 1, 2012 CY 2014 Medicare

ASC-6 Safe Surgery Checklist Use Web-Based CY 2012 July – August 2013

CY 2015 All

ASC-7 ASC Facility Volume Data on Selected ASC Surgical Procedures

Web-Based CY 2012 July – August 2013

CY 2015 All

ASC-8 Influenza Vaccination Coverage among Healthcare Personnel

Web-Based via NHSN

Entry TBD; October 2014 – March

2015

CY 2016 Health Care Personnel

ASC-9 Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients


2015

CY 2016 Sampling

ASC-10 Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use


2015

CY 2016 Sampling

ASC-11 Cataracts – Improvement in Patient’s Visual Function within 90 days Following Cataract Surgery


2015

CY 2016 Sampling


• 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.*



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

http://ascquality.org/qualitymeasures.cfm



http://www.ascassociation.org/

http://qualitynet.org/



Additional QuestionsContact FMQAI for Program Questions at

[email protected] 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 [email protected] via phone (866) 288-8912 Monday through Friday, 7 a.m. to 7 p.m. Central Time

mailto:[email protected]


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






http://ascquality.org/documents/ASCQualityCollaborationImplementationGuide.1.6.pdf



Questions/Comments

Gina Throneberry, RN, MBA, CASC, CNORAmbulatory Surgery Center Association (ASCA)

Director or Education and Clinical Affairs [email protected]


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