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 the first Ambulatory Surgical Center Quality Reporting (ASCQR) Program data was submitted beginning October 1, 2012.
For reporting in 2023, there are eight measures required for eligible Medicare-certified facilities* to avoid Medicare payment reductions in 2024. The deadline for submitting ASCQR Program data is May 15, 2023. 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 2023.
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 2022 must be submitted via the HQR Portal by May 15, 2023.
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 2022 must be submitted via the HQR Portal by May 15, 2023.
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 2022 must be submitted via the HQR Portal by May 15, 2023.
ASC-20: COVID-19 Vaccination Coverage Among Health Care Personnel data is submitted quarterly via a web-based tool, the National Healthcare Safety Network (NHSN). The 2023 reporting deadlines are February 15, 2023 (2022 third quarter data), May 15, 2023 (2022 fourth quarter data), August 15, 2023 (2023 first quarter data) and November 15, 2023 (2023 second quarter data).
Please note that data collection resumed on January 1, 2023 for ASC-1: Patient Burn; ASC-2: Patient Fall; ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant; and ASC-4: All-Cause Hospital Transfer/Admission. Facilities will not report these measures on claims as was previously required. Instead, ASCs must collect data for these measures for all patients, not just fee-for-service (FFS) Medicare beneficiaries.This data must be reported through the HQR secure portal by May 15, 2024.
Visit ASCA's 2023 Quality Reporting Requirements web page for information on changes to ASCQR requirements in 2023, 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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