Quality Reporting

In 2006, the ASC community began encouraging the Centers for Medicare & Medicaid Services (CMS) to establish a uniform quality reporting system that would allow ASCs to publicly demonstrate their performance on quality measures. CMS listened and implemented the Ambulatory Surgical Center Quality Reporting (ASCQR) Program on October 1, 2012.

For reporting in 2018, there are eight measures required for eligible Medicare-certified facilities* to avoid Medicare payment reductions in 2019.

*ASCs that have fewer than 240 Medicare claims (primary plus secondary payer) per year during a reporting period for a payment determination year would not be required to participate in the ASCQR Program for the subsequent reporting period for that subsequent payment determination year. This includes all program requirements, both claims-based and measures entered via a web-based tool.

Here is a breakdown, by measure, of what is required.

  • ASCs must continue to report on measures ASC-1: Patient Burn, ASC-2: Patient Fall, ASC-3: Wrong Site/Side/Patient/Procedure/Implant and ASC-4: Hospital Admission/Transfer. These claims-based measures are entered as G-codes on the CMS-1500 claim form.

  • ASC-8: Influenza Vaccination Coverage among Healthcare Personnel data collection will take place for the influenza season between October 1, 2017, and March 31, 2018. The reporting deadline is May 15, 2018. To report ASC-8 through the National Healthcare Safety Network (NHSN) as required, someone from your ASC must register with NHSN. This registration process can take several weeks, so ASCs are advised to register immediately. Click here for instructions.

  • ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients and ASC-10: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use are web-based measures that are also reported via QualityNet. This aggregate data must be reported by all Medicare-certified ASCs, regardless of specialty or case mix. If your center does not perform colonoscopies, for both ASC-9 and ASC-10 you will enter “0” in the numerator and the denominator. Just as with ASC-6 and ASC-7, these measures must be reported between January 1 and May 15, 2018.

  • Citing operational concerns with the measure, CMS has made ASC-11: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery a voluntary measure. Please note that if you choose to participate in reporting this voluntary measure, any data reported will become publicly available.

  • Facilities do not need to report data for ASC-12: Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy as the data will be pulled from claims previously submitted by the hospital that the patient visits within seven days of the colonoscopy.

Visit ASCA's 2018 Quality Reporting Requirements web page for more information.

In addition, there are two new measures on which ASCs will need to begin collecting data in 2018 and report on beginning in 2019. These new measures are listed below.

  • ASC-13: Normothermia Outcome is used to assess the percentage of patients having surgical procedures under general or neuraxial anesthesia of 60 minutes or more in duration who are normothermic within 15 minutes of arrival in PACU.

  • ASC-14: Unplanned Anterior Vitrectomy is used to assess the percentage of cataract surgery patients who have an unplanned anterior vitrectomy.

More information on these measures is available in the current Ambulatory Surgical Center Quality Reporting Specifications Manual.

Additional Resources


ASC Quality Reporting Measures Specifications Manual

ASCQR Program Resources

ASCQR Program Reference Checklist

ASC-8: What You Need to Know to Successfully Report

National Healthcare Safety Network

OAS CAHPS Survey® FAQs

Quality Data G-Codes

QualityNet

Safe Surgery Checklist Information



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