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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.

There are currently five measures on which Medicare-certified facilities are required to report in order to avoid future Medicare payment reductions. In 2015, Medicare-certified facilities will be required to report data on 10 quality measures.

Here is a breakdown, by measure, of what is currently required:

  • ASCs must continue to report on measures ASC-1: Patient Burn, ASC-2: Patient Fall, ASC-3: Wrong Site/Side/Patient/Procedure/Implant, ASC-4: Hospital Admission/Transfer and ASC-5: Prophylactic Intravenous (IV) Antibiotic Timing. These claims-based measures are entered as G-codes on the CMS-1500 claim form.

  • ASC-6: Safe Surgery Checklist Use and ASC-7: ASC Facility Volume Data on Selected ASC Surgical Procedures data was collected in 2013 but will not be reported in 2014.* Data reporting will resume in 2015, via CMS’ QualityNet web site.

*The 2014 ASC final payment rule indicated that this was being done in order to align the reporting periods across all measures on a three-year cycle. Data is collected the first year and reported the second year and the payment determinations are impacted in the third year. Data must continue to be collected in 2014 to be reported in 2015.

  • ASC-8: Influenza Vaccination Coverage among Healthcare Personnel data collection will take place for the influenza season between October 1, 2014, and March 31, 2015. The reporting deadline is May 15, 2015. To report ASC-8 through the National Healthcare Safety Network (NHSN) as required, someone from your ASC must register with NHSN. This registration process can take several weeks, so ASCs are advised to register immediately. Click here for instructions.

  • ASC-9: Endoscopy/Poly Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients and ASC-10: Endoscopy/Poly Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use are web-based measures that will be reported via QualityNet in 2015. This aggregate data must be reported by all Medicare-certified ASCs, regardless of specialty or case mix. If your center does not perform colonoscopies, for both ASC-9 and ASC-10 you will enter “0” in the numerator and the denominator.

  • Citing operational concerns with the measure, CMS has made ASC-11: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery a voluntary measure. Please note that if you choose to participate in reporting this voluntary measure, any data reported may become publicly available in the future.

  • 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.

Visit ASCA's 2015 Quality Reporting Requirements webpage for more information.

Additional Resources

ASC Quality Reporting Measures Specifications Manual 4.0

ASC-8: What You Need to Know to Successfully Report

Quality Data G-Codes

Safe Surgery Checklist Information

2014 Final Rule Quality Reporting FAQs

Sample CMS-1500 Claim Form

Reproduction in whole or in part without written permission from ASCA is prohibited.