ASC Quality Reporting Program

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 2024, there are 12 measures required for eligible Medicare-certified facilities* to avoid future Medicare payment reductions. The deadline for submitting most ASCQR Program data is May 15, 2024. Please note that the QualityNet secure portal was reengineered into the Hospital Quality Reporting (HQR) secure portal.

Here is a breakdown, by measure, of what is required in 2024.

• 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 are outcome measures that were previously suspended as of January 1, 2019 but data collection resumed in CY 2023 for reporting via the HQR Secure Portal in CY 2024. Data for these measures must be collected for all patients, not just fee-for-service Medicare beneficiaries, and must be submitted by May 15, 2024.
• 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 secure 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 2023 must be submitted via the HQR secure portal by May 15, 2024.
• Facilities do not need to report data for ASC-12: Facility 7-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 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. 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 2023 must be submitted via the HQR secure portal by May 15, 2024.
• 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 2023 must be submitted via the HQR secure portal by May 15, 2024.
• ASC-17: Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures 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 Ambulatory Surgical Centers 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 is submitted quarterly via a web-based tool, the National Healthcare Safety Network (NHSN). The 2024 reporting deadlines are February 15, 2024 (2023 third-quarter data), May 15, 2024 (2023 fourth-quarter data), August 15, 2024 (2024 first-quarter data) and November 15, 2024 (2024 second-quarter data).

Please note that ASC-15 a-e: Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey measures are available for voluntary reporting in CY 2024, with mandatory reporting beginning with the CY 2025 reporting period for CY 2027 payment determination. CMS has added two approved survey modes: electronic with phone and electronic with mail. ASCs must use an approved OAS CAHPS Survey vendor: and pre-register via the OAS CAHPS website. For more information, visit our OAS CAHPS Survey page.

Visit ASCA's ASCQR Program requirements webpage for information on changes to ASCQR Program requirements in 2024, 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.

*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.

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