Quality Reporting Updates ASCs Should Know

Written by: Crissy Benze, MSN, BSN, RN

The Ambulatory Surgical Center Quality Reporting (ASCQR) Program is a pay-for-reporting, quality data program from Centers for Medicare & Medicaid Services (CMS). Initially introduced in the 2012 Outpatient Prospective Payment System (OPPS)/Ambulatory Surgery Center (ASC) Final Rule, the program has since evolved as a result of annual revisions and updates.

For ASCs to receive the full annual update to their payment rate, they must report quality of care data for standardized measures; the measures can be found in the ASC Quality Reporting Specifications Manual. The current versions — which can be found on the QualityNet website — are 8.0a for encounter dates of 1/1/19 – 12/31/19 and 9.0a for encounter dates 1/1/20 – 12/31/20.

ASC Quality Reporting Measures

In 2020, ASCs are required to report data on the below measures in order to avoid a reduction in the following year’s Medicare reimbursement:

  • ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients
  • ASC-11: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery (remains voluntary)
  • ASC-12: Facility 7-Day Risk-Standardized Hospital Visit Rate After Outpatient Colonoscopy
  • ASC-13: Normothermia Outcome
  • ASC-14: Unplanned Anterior Vitrectomy
  • ASC-17: Hospital Visit After Orthopedic Ambulatory Surgery Procedures
  • ASC-18: Hospital Visit After Urology Ambulatory Surgery Procedures

Measures that are currently unavailable for ASCs to select from are:

  • 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
    • These measures have not been removed from the ASCQR Program, but they remain suspended until further rule making.
  • ASC-19: Hospital Visit After General Ambulatory Surgery Procedures
    • This measure has been approved but data won’t start being collected until Jan. 1, 2021.

How to Report

ASCs must report data for measures ASC-9, ASC-11 (a voluntary measure), ASC-13, and ASC-14 through the QualityNet website by May 15, 2020. To access the secure portal, each facility must have an active security administrator login; it is recommended that you have at least two per facility. To ensure the account remains active, the administrator(s) must sign-in frequently (at least every 60 days). Please note that even if you do not perform the specific procedures related to those measures, you still need to report by entering a zero for both the numerator and denominator.

There is no data submission or reporting required of ASCs for measures 12, 17, and 18. Rather, data is pulled by CMS from the Medicare Fee for Service administrative claims billed by the facility. These reports, which include patient-level data, will be uploaded to the QualityNet Secure Portal.

Measure ASC-19 is also administrative claims-based, so there will be no data submission required by ASCs when this starts in 2021.

Future Measures

The ASCQR Program is reviewed and updated annually with changes published in the ASC Final Rule every November. The below measures are currently being considered for future updates.

  • ASC-15 (a-e): Outpatient/Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS)
    • This measure remains delayed but will be added at some point in the future.
  • Ambulatory Breast Procedure Surgical Site Infection (SSI) Outcome Measure

Happy Reporting

The ASCQR Program remains a pay-for-reporting and not pay-for-performance system. All you have to do to ensure there are no payment reductions for your facility is complete data submission reporting each year per the Specifications Manual ASC Quality Reporting. With that said, happy reporting this year.

LEARN MORE: Join guest speaker Gina Throneberry, director of education and clinical affairs for the Ambulatory Surgery Center Association (ASCA), for a free 20-minute webinar that will cover CMS quality reporting on Jan. 27, at 11 a.m. PST / 2 p.m. EST. Register today.

ADDITIONAL RESOURCE: Through the Quality Reporting Center website, you can perform research and compare ASCQR Program quality measure information for the past payment year. There is also the option to access measure data from other ASCs by their city and state or ZIP code for comparison purposes.