1. When are ASCs supposed to start using G codes?
The October 1, 2012 date is the mandatory date for the five measures (patient fall; patient burn; wrong site, side, patient, procedure, implant; hospital transfer/admission, and prophylactic antibiotic timing). These would be reported on the claims form (UB1500) for Medicare Part B Fee for Service patients using G codes. The April 1, 2012 date is the date you can start using G codes on your claims.
2. Where are the G Codes reported on the claim form?
Quality-data codes (QDC) must be entered on the Form CMS-1500 and have an associated charge in order to be accepted into the CMS warehouse. These codes will populate Fields 24D and 24F on the Form CMS-1500.
The submitted charge field cannot be blank.
The line-item charge should be the numeral "0" (zero). Please note that dollar signs ($) or decimal points are not accepted.
If a system does not allow a zero line-item charge, a nominal amount can be substituted; the beneficiary is not liable for this nominal amount.
Entire claims with a zero charge will be rejected. The total charge for the claim cannot be zero.
When a zero charge or a nominal amount is submitted to the carrier or contractor, payment for the amount included in the ASC QDC line is denied and tracked.
3. Would only G8907 be used if the patient did not experience any of the events?
Yes, however one of the antibiotic codes would need to be chosen: G8917, G8917, G8918; for a minimum of two codes.
4. If the patient did experience an event, such as hospital transfer/admission, is the code G8914 used, or are all of the additional codes stating that the patient did not experience those events. (G8909, G8911, G8913 and G8918) listed also?
For a patient that experienced a hospital transfer/admission and no other event, the following codes would be used:
G8914, patient experienced a hospital transfer/admission,
G8909, patient did not experience a burn,
G8911, patient did not experience a fall,
G8913, patient did not experience a wrong,
You would then have to also choose one of the antibiotic codes: G8917, G8917, G8918; for a maximum of five codes.
1. Are the ASC quality measures for patients who have Medicare Replacement (Medicare Managed Care) primary reported?
Data for claims-based measures included in the CMS Specifications Manual are to be reported for all Medicare Part B Fee-for-Service (FFS) patients admitted to the ASC during required reporting periods. Medicare Part B FFS patients include Medicare Railroad Retirement Board patients and Medicare Secondary Payer patients. Medicare Advantage patients are not included.
Reporting on claims-based measures begins on October 1, 2012 for all Medicare Part B FFS patients, with the exception of Medicare Secondary Payer patients. Reporting on claims-based measures for Medicare Secondary Payer patients begins on January 1, 2013.
2. How will Medicare notify Medicare Administrative Contractors whether an ASC is compliant with reporting and can have full payment, or whether an ASC is NOT compliant and deserves the 2% reduction?
CMS routinely provides payment update files (e.g. annual and quarterly) to its contractors for download from the CMS mainframe.
3. For patients that have Medicare primary and a commercial secondary that currently gets electronically crossed from Medicare, will the secondary still get electronically crossed? Will the secondaries accept the G code or will that claim be rejected by the secondary? Will Medicare remove the G codes prior to sending?
It is suggested to run a test with the claims for the facility prior to the October 1, 2012 date. It is believed each payer and state intermediary will be different.
4. Will primary payers reject the claim if the two – five codes are appended onto their claim? In the majority of these cases the claim automatically crosses over to Medicare without the ability to intervene and add the codes after the primary payer adjudicates the claim. Logistically it is uncertain how to append the G codes to the claim when it will automatically crossover from the primary and/or the primary will reject the claim outright due to the presence of the G codes they do not recognize.
CMS is aware of these issues and has been working with the cross over benefits contractor in this regard and are planning outreach to clearinghouses, carriers, and private payers. Because the Quality Data Codes (QDCs) are approved G-codes, payers should be accepting them; however CMS knows that some have not been accepting them.
CMS has proposed that the minimum threshold for data completeness for the first two years of the program is at 50%. Reporting on claims-based measures begins on October 1, 2012 for all Medicare Part B Fee-for-Service patients, with the exception of Medicare Secondary Payer patients. Reporting on claims-based measures for Medicare Secondary Payer patients begins on January 1, 2013.
5. Do we have to report data for Medicare patients only or for all patients?
This answer depends on the reporting measure. The first five measures (patient fall; patient burn; wrong site, side, patient, procedure, implant; hospital transfer/admission, and prophylactic antibiotic timing) listed in the CMS ASC Quality Reporting Program Specifications Manual at www.ascquality.org (click on the ASC tab) will need to be reported using the Quality Data Codes (QDCs). The ASC will need to report these measures only for Medicare Part B Fee-for-Service (FFS) beneficiaries. Medicare Part B FFS patients include Medicare Railroad Retirement Board patients and Medicare Secondary Payer patients. Medicare Advantage patients are not included. Reporting on claims-based measures begins on October 1, 2012 for all Medicare Part B FFS patients, with the exception of Medicare Secondary Payer patients. Reporting on claims-based measures for Medicare Secondary Payer patients begins on January 1, 2013.
The HCPCS Level II G codes or Quality Data Codes can be found in the CMS ASC Quality Reporting Program Specifications Manual.
Beginning in 2013, however, ASCs will be required to report their total—Medicare and non-Medicare—January 1 through December 31, 2012 surgical volume for certain specified procedures (see specifications manual for the list).
The other two measures that have been announced—Safe Surgery Checklist Use and Influenza Vaccination Coverage among Health Care Personnel—are not patient-specific. They apply to the general operation of the ASC.
6. What it the definition of an ambulatory surgery center?
According to the Medicare Claims Processing Manual, Chapter 14, an ASC is a distinct entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients. The ASC must have in effect an agreement with CMS obtained in accordance with 42 CFR 416 subpart B (General Conditions and Requirements). An ASC is either independent (i.e., not a part of a provider of services or any other facility), or operated by a hospital (i.e., under the common ownership, licensure or control of a hospital). A hospital-operated facility has the option of being considered by Medicare either to be an ASC or to be a provider-based department of the hospital as defined in 42 CFR 413.65
If a facility meets the requirements to participate as an ASC, it bills the Medicare contractor on Form CMS-1500 or the related electronic data set and is paid the ASC payment amount.
7. Nurses routinely document what happened, not what didn't happen. If there's a patient burn, it's documented; if not, nothing is mentioned in the chart. In order to use the QDC codes, is this documentation required?
Nurses are trained to document what happened, not what didn't happen. For instance, if there is a hospital transfer, that transfer is documented on a special form and there are references to it in the chart. If there is no hospital transfer, then there is no documentation. If there's a patient burn, it's documented; if not, nothing is mentioned in the chart.
On the other hand, billers will tell you that if something on the coding side isn't documented, it can't be coded. If they are going to put a code on a bill, there has to be supporting documentation.The coders want to know if some sort of sheet is needed in the patient chart that staff can check off to say there was no patient transfer, there was no fall, or burn, etc. Since the codes are not being used to collect funds, but rather for quality, maybe this doesn't matter. What is being expected as far as documentation?
Documentation of non-events is not required. However, if your coding department is requiring such documentation, you may develop a tool that allows you to document the information in a yes/no format, or a sheet with the items printed on it with a space for when it was completed, by whom and the appropriate signature, date, time and so forth.
1. What if a surgery center never administers IV antibiotics pre-operatively? According to the Specifications Manual a facility with an order for a pre-operative antibiotic order that isn't administered via IV is excluded. Does this mean it would be reported, for a patient with no reportable events, G8907 and G8918 or just G8907?
In the specifications manual, the exclusion was there to clarify that you would not include admissions with an order for antibiotics not administered by the intravenous route such as antibiotics given orally, topically, etc. For the G codes, there are no exclusions so you would use G8907 if the patient has no events and G8918, no order for IV antibiotic for the scenario described. There would be a minimum of two G codes and a maximum of five G codes.
2. Occasionally we give Spontaneous Bacterial Endocarditis (SBE) antibiotics prior to our endoscopies. Does SBE prophylaxis antibiotics count toward the prophylactic antibiotic quality measure or is that exempt?
Per the ASC Quality Collaboration Implementation guide's FAQs found at www.ascquality.org on the left side of the home page:
If an antibiotic is ordered for the prophylaxis of spontaneous bacterial endocarditis (SBE), should we count it? No, the only antibiotics administered for the prophylaxis of surgical site infection are included for measurement.
3. When two IV antibiotics are ordered (written on the chart) pre operatively such as Gentamycin IV and Ancef IV, do both antibiotics have to be initiated within the hour prior to surgery start?
Yes, this is addressed in the implementation guide found at www.ascquality.org on the left hand side of the home page under FAQs:
What happens when two or more prophylactic antibiotics are given to the same patient for the same procedure?
The infusion of all prophylactic IV antibiotics ordered for surgical site infection would need to be initiated within the one-hour time frame (two hours for vancomycin or fluoroquinolones). In cases involving more than one antibiotic, all antibiotics must be initiated within the appropriate time frame in order for the case to meet criteria.
4. The specifications manual states "introduction of endoscope" for timing of antibiotics. If a center performs endoscopic ultrasound the patient could be scoped for 15-20 minutes before the decision is made to do a fine needle aspiration. The antibiotics would be given after the introduction of the endoscope, but before the needle is inserted. In this scenario would the antibiotic still be considered to be given on time?
In the scenario above, the order for prophylaxis is an intraoperative/intraprocedural one. Because the order is not preoperative, the case would not be included in the denominator, and the center would report G8918.
5. If a patient is allergic to Ciprofloxacin and Primaxin is given, would this be reported since Primaxin is not on the antibiotic list for prophylaxis of surgical site infections (SSI)?
If the order was given beforehand, Cipro would be included and the center would report G8916 or G8917 depending on the timeliness. If Primaxin was ordered beforehand, it is not considered prophylactic for SSI for purposes of this measure, and the center would report G8918.
1. If center personnel assist a patient down, that is not uncontrolled, would that be considered a fall?
Per the ASC Quality Collaboration Implementation Guide found at www.ascquality.org:
Should we count assisted falls under this measure?Yes, assisted falls are considered falls for the purposes of this measure.
2. If a patient becomes light headed, assisted down, but does not lose consciousness, would that be considered a fall?
Per the ASC Quality Collaboration Implementation Guide found at www.ascquality.org:
Should we count assisted falls under this measure? Yes, assisted falls are considered falls for the purposes of this measure.
1. If a patient is admitted to preop and transferred to the hospital for a clinical reason, the center would not ordinarily submit a claim. Is it required to submit a claim with the modifier for the case cancelled prior to anesthesia, in order to submit the G code for the patient transfer? Since the center would not ordinarily submit a claim for this patient, is there the obligation to report the transfer?
Under Physician Quality Reporting System (PQRS), claims are not submitted solely for the purposes of reporting quality codes. It is believed the same policy will be in place for the ASC Quality Reporting Program, so if the facility is not going to submit a claim for billing purposes, no Quality Data Codes would be reported.
2. Should patients who go to the hospital or emergency room sometime after their discharge from the ASC be counted?
No, the patient has to be transferred directly from the ASC to the hospital or emergency room.
1. Does the Safe Surgery Checklist need to be a paper document or can it be a process? If it cannot be a process, can there be just a checkbox that states safe surgery checklist completed?
The CMS ASC Quality Reporting Program Quality Measures Specifications Manual on page 19 states:
The use of a Safe Surgery Checklist for surgical procedures that includes safe surgery practices during each of the three critical perioperative periods: the period prior to the administration of anesthesia, the period prior to skin incision, and the period of closure of incision and prior to the patient leaving the operating room.
CMS does not state any requirement for documentation at the patient level. This is the decision of the facility.
1. If a patient had three procedures done on one visit, would the center report all three codes used on that one patient? Would the VOLUME be "3" or "1"?
We have asked CMS to clarify. To date, they have stated "aggregate count of selected surgical procedures per category".
1. When can ASCs register for the CDC site?
ASCs should wait to register on the CDC’s National Healthcare Safety Network (NHSN) site, unless the facility is in a state with mandatory reporting. The understanding is that the registration process is going to be streamlined by CDC for ASCs in the future.
1. Where will the audio from the ASCA Quality Reporting webinar be available?
Click here to access the recording and the handouts.
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