Quality Reporting Alert (July 7, 2015)

July 7, 2015

All Medicare-certified ASCs must submit quality reporting data to the Centers for Medicare and Medicaid Services’ (CMS) ASC Quality Reporting Program on five measures (ASC-6 through ASC-10) by August 15, 2015, or risk a two percentage point reduction in their Calendar Year (CY) 2016 annual payment update from CMS. Information that CMS distributed recently regarding several of these measures has caused some confusion and generated a significant number of questions on the current requirements.

To ensure that your ASC is clear on the web-based reporting that is required to be completed by August 15, 2015, ASCA has provided the instructions below.

ASC-8: Influenza Vaccination Coverage Among Healthcare Personnel

To successfully report on this measure via the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN), you must be enrolled with NHSN using your ASC’s correct CMS Certification Number (CCN). Your ASC’s CCN is an alphanumeric 10-digit number. The first two digits represent your state’s number, and the following letter is a “C.”

Because the NHSN reporting system does not notify users when they submit an invalid CCN (such as N/A or an incorrect number) and will allow users to complete the process as if the system has accepted their information although it has not, all ASCs are advised to verify that their CCN was entered correctly for their NHSN account. As of April, there were at least 400 facilities that had entered N/A or an incorrect number (less than 10 digits). If you did not enter a correct CCN for your facility, your facility will not be given credit for NHSN data entry for the ASC Quality Reporting Program even though you submitted the requested data.

You MUST enter your facility’s correct CCN in NHSN.

To verify or correct a CCN, take the following steps:

1. Use the ASC CCN Lookup Tool to ensure that your facility’s CCN corresponds to your facility’s National Provider Identifier (NPI).

2. Change your facility’s CCN within the NHSN system by following these steps.

After confirming that you have entered the correct CCN for your facility and that you have completed enrollment, enter your data and save screenshots of the completed data submission screen for your records. NHSN may ask to see these screenshots later.

Measures Submitted Via QualityNet (ASC-6, 7, 9 and 10)

Make sure you are reporting for the correct year. You must log in to the QualityNet Secure Portal and verify that you entered data for Payment Year 2016. One the data is submitted properly, a green check mark will appear. ASCA has been informed that some facilities that thought they had completed reporting were mistakenly looking at Payment Year 2015.

Make sure you are reporting on all required measures. Log in to the QualityNet Secure Portal and verify that you entered data for all four web-based measures. For any procedures that you do not perform that are included in ASC-7 (ASC Facility Volume Data on Selected ASC Surgical Procedures), you must enter zeroes. The same is true for ASC-9 and ASC-10; even if you do not perform colonoscopies, you must enter zeroes for these two measures.

For additional questions related to NHSN, please email nhsn@cdc.gov. For additional questions related to your Security Administrator account or data concerning the web-based measures submitted through QualityNet, contact the Support Contractor at oqrsupport@hsag.com or at 866.800.8756.