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ASC Quality Reporting Program
Jovanna Grissom, RN, CASC, CIC, CNOR
Regional Vice President, Operations
Overview
• Changes every year
• Deadlines/rules are subject to change
• Currently we are collecting on 11 measures
• ASCQR Program Proposed Rule begins on page
37193 in the Federal Register
General Rules
• All ASCs reimbursed under the ASC fee schedule for
Medicare are subject to the ASCQR Program
requirements:
o If your ASC has been in business at least 4 months prior to
January 1
oMagic number is 240 Medicare claims (primary plus
secondary)
Payment Determination
• The Ambulatory Surgical Center Quality Reporting
(ASCQR) Program is a pay-for-reporting, quality data
program finalized by the Centers for Medicare &
Medicaid Services (CMS).
• Under this program, ASCs report quality of care data for
standardized measures to receive the full annual update
to their ASC annual payment rate, beginning with
calendar year (CY) 2014 payments.
Data Collection/Reporting/Payments
Data Collection Reporting Data Payment Affected
2017 2018 2019
2018 2019 2020
2019 2020 2021
Methods of Reporting
1. CMS-1500 form or associated electronic data set
2. Quality Net
3. NHSN
Quality Net
• Reporting
• Supportive Resources
• Questions & Answers
• ListServ Registration
• Reporting Specifications Manual
ASC Quality Reporting Specifications Manual
Data Collection Time Period Specifications Manual
01/01/19 - 12/31/19 Version 8.0
01/01/18 - 12/31/18 Version 7.0a
The Ambulatory Surgical Center Quality Reporting Program Quality
Measures Specifications Manual provides measure information and
specifications for Medicare’s ASC Quality Program. These
standardized measures were selected by CMS to measure the quality
of care for patients in the ASC.
Quality Net
• Quality Reporting Center
– Reference and training materials
– Educational presentations
– Timelines and calendars
– Data collection tools
– Contact information
– Helpful links to resources
– Question and answer tools
Quality Reporting Center Log In
Resource: ASC Quality Collaboration
• Measuring Development
• Reporting to the Public
• Advancing ASC Quality
Patient Burn in the ASC: ASC - 1
Patient Fall in the ASC: ASC - 2
Wrongs in the ASC: ASC - 3
Transfers in the ASC: ASC - 4
Normothermia: ASC - 13
Unplanned Anterior Vitrectomy: ASC - 14
National Healthcare Safety Network (NHSN)
• Reporting
• HAI Tracking
• Protocols
• Support Materials
During 2016-2017 flu season
• CDC estimates the influenza vaccination prevented
approximately 5.3 million influenza illnesses
• 2.6 million influenza-associated medical visits
• 85,000 influenza-associated hospitalizations
Overall vaccine effectiveness = 40%
Influenza Stats
Healthcare Vaccinations
• Flu vaccination occurrence
– 85.8% among healthcare providers (HCP) whose
employers required they be vaccinated
– 68.45% among HCP whose employers recommended they
be vaccinated
– 43.4% among HCP whose employers did not have a policy
or recommend vaccination
• The most common reasons reported by HCP for not getting
vaccinated were:
1. They did not think the flu vaccination worked.
2. They did not think they needed the vaccination.
CDC 2015
Bruce Bardall, BSN, MS, RN,CNOR
Director Clinical Support/Operations
2019 OPPS/ASC Proposed Rule: Quality Reporting
ASCQR Program
Federal Register Link
https://www.federalregister.gov/docume
nts/2018/07/31/2018-15958/medicare-
program-proposed-changes-to-hospital-
outpatient-prospective-payment-and-
ambulatory-surgical
The ASCQR Program section begins on
p. 37193 of the Federal Register
Access Your Program Section
CY 2018 OPPS Final Rule
Claims-Based Measures
ASC-1 Patient Burn
ASC-2 Patient Fall
ASC-3 Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant
ASC-4 All-Cause Hospital Transfer/Admission
ASC-12 Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy
Adopted for CY 2022 Payment Determination
ASC-17 N/A Hospital Visits after Orthopedic Ambulatory Surgical Center Procedure
ASC-18 N/A Hospital Visits after Urology Ambulatory Surgical Center Procedures
Web-Based Measures
ASC-8 Influenza Vaccination Coverage among Healthcare Personnel
ASC-9 Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average
Risk Patients
ASC-10 Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous
Polyps-Avoidance of Inappropriate Use
ASC-11 Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery
(Voluntary)
ASC-13 N/A Normothermia Outcome
ASC-14 N/A Unplanned Anterior Vitrectomy
OAS CAHPS Survey
ASC-15 OAS CAHPS Survey Delayed Implementation
Meaningful Measures Initiatives
Minimizing Cost
• Collection burden and related costs of quality reporting
• Compliance with requirements of other quality programs
• Tracking similar or duplicative measures
• Program oversight by CMS
• Compliance with federal and/or state regulations
Improving Data Usefulness
• Usability of CMS quality program data by streamlining how facilities are
reporting and accessing data
• Consumer understanding of data reported publicly on a Compare website
Measures Aligned for Hospital OQR and ASCQR
Alignment Goals and Meaningful Measure Areas
ASCQR Measures Set as Proposed
Measure CY 2020 and Subsequent
Payment Determinations
ASC-1: Patient Burn Proposed Removal CY 2021
ASC-2: Patient Fall Proposed Removal CY 2021
ASC-3: Wrong Site, Wrong Side, Wrong Patient,
Wrong Procedure, Wrong Implant Proposed Removal CY 2021
ASC-4: All-Cause Hospital Transfer/Admission Proposed Removal CY 2021
ASC-8: Influenza Vaccination Coverage among Proposed Removal CY 2020
Healthcare Personnel
ASCQR Measures Set as Proposed
Measure CY 2020 and Subsequent
Payment Determinations
ASC-9: Appropriate Follow-Up Interval Proposed Removal CY 2021
for Normal Colonoscopy in Average
Risk Patients
ASC-10: Colonoscopy Interval for Patients Proposed Removal CY 2021
with a History of Adenomatous Polyps –
Avoidance of Inappropriate Use
ASC-11: Cataracts: Improvement in Patient’s Proposed Removal CY 2021
Visual Function within 90 Days Following
Cataract Surgery
ASCQR Measures Set as Proposed
Measure CY 2020 and Subsequent
Payment Determinations
ASC-12: Facility 7-Day Risk-Standardized Hosptial
Visit Rate after Outpatient Colonoscopy Proposed Removal CY 2021
ASC-13: Normothermia Outcome Yes
ASC-14: Unplanned Anterior Vitrectomy Yes
ASC-17: Hosptial Visits After Orthopedic Beginning CY 2022
Ambulatory Surgery Center
Procedures
ASC-18 Hosptial Visits After Urology Beginning CY 2022
Ambulatory Surgery Center
Procedure
References
https://www.federalregister.gov/documents/2018/07/31/20
18-15958/medicare-program-proposed-changes-to-
hospital-outpatient-prospective-payment-and-ambulatory-
surgical
ASCQR Technical Expert Committee
QualityNet
NHSN
Questions?Bruce Bardall, MS, BSN, RN, CNOR
Director Clinical Support
physiciansendoscopy
2500 York Road, Suite 300
Jamison, PA 18929
Direct: (267) 885-3829
