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 2022, there are eight measures required for eligible Medicare-certified facilities* to avoid Medicare payment reductions in 2023. The deadline for submitting ASCQR Program data is May 16, 2022, due to May 15 falling on a Sunday this year. Please note that QualityNet Secure Portal was re-engineered into the Hospital Quality Reporting (HQR) Secure Portal.

*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.

Here is a breakdown, by measure, of what is required in 2022.

  • ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients is a web-based measure that is reported via the HQR Portal. This aggregate data must be reported by all Medicare-certified ASCs, regardless of specialty or case mix. If your center does not perform colonoscopies, select the box under the measure name and description that states “Please enter zeros for this measure as I have no data to submit.” Data collected in 2021 must be submitted via the HQR Portal by May 16, 2022.

    • 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.

    • ASC-13: Normothermia 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. Like ASC-9, this is a sampling measure. If your center does not perform procedures related to this measure, select the box under the measure name and description that states “Please enter zeros for this measure as I have no data to submit. Data collected in 2021 must be submitted via the HQR Portal by May 16, 2022.

    • ASC-14: Unplanned Anterior Vitrectomy is used to assess the percentage of cataract surgery patients who have an unplanned anterior vitrectomy. If your center does not perform procedures related to this measure, select the box under the measure name and description that states “Please enter zeros for this measure as I have no data to submit. Data collected in 2021 must be submitted via the HQR Portal by May 16, 2022.

    • Facilities do not need to report data for ASC-17: Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures as the data is pulled from claims previously submitted by the hospital that the patient visits within seven days of the orthopedic procedure.

    • Facilities do not need to report data for ASC-18: Hospital Visits after Urology Ambulatory Surgical Center Procedures as the data is pulled from claims previously submitted by the hospital that the patient visits within seven days of the urology procedure.

    • Facilities do not need to report data for ASC-19: Facility-Level 7-Day Hospital Visits after General Surgery Procedures Performed at ASCs as the data is pulled from claims previously submitted by the hospital that the patient visits within seven days of the general surgery procedure.

    • ASC-20: COVID-19 Vaccination Coverage Among Health Care Personnel data will be submitted via a web-based tool, the National Healthcare Safety Network (NHSN). The first reporting deadline is August 15, 2022, for first quarter data (January, February and March 2022).

    Visit ASCA's 2022 Quality Reporting Requirements web page for information on changes to ASCQR requirements in 2022, and the Ambulatory Surgical Center Quality Reporting Specifications Manual for more information on all measures. Additional resources, such as reporting dates and measure resources, can be found on CMS' ASCQR Program Resources webpage.


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