Quality Reporting FAQs

The Centers for Medicare & Medicaid Services (CMS) recently announced details of its new quality reporting program for ASCs, which will begin in 2012. Under the program, ASCs that fail to report required information will face a 2% reduction in their Medicare payments. This document provides answers to some frequently asked questions about the program. Click here for additional FAQs from the webinar “Quality Measure Reporting in 2012.” ASCA members with further questions can contact ASCA’s Member Services Team at asc@ascassociation.org or 703.836.8808 for answers.

CMS has indicated that it will continue to publish more answers to questions about Medicare’s quality reporting program in regular updates of the program’s specifications manual. Click here for the latest version of the manual.

1. What measures will we be required to report? When will we be required to report them?

As of October 1, 2012, ASCs will be required to report data on the following five quality measures:

1. Patient Burn

2. Patient Fall

3. Wrong Site/Side/Patient/Procedure/Implant

4. Hospital Admission/Transfer

5. Prophylactic IV Antibiotic Timing

2013 will usher in the addition of two more measures:

1. Safe Surgery Checklist Use in 2012

2. 2012 Volume of Certain Procedures

While ASCs won’t be required to report information on these last two measures until 2013, at that time, they will be expected to report data based on activities conducted in 2012. This means that an ASC should ensure that it is using a safe surgery checklist and has a system in place to capture surgical volume data on January 1, 2012. ASCs that want to avoid financial penalties will need to report whether or not they were using a safe surgery checklist at any time between January 1, 2012, and December 31, 2012. If a high percentage of ASCs report that they did not use a safe surgery checklist in 2012, CMS’s public reporting of that information could generate negative news stories and concerns among patients and providers.

In 2014, one additional measure, Influenza Vaccination Coverage Among Health Care Personnel, is slated to be added to the list of quality reporting measures. This measure assesses the percentage of health care personnel (HCP) who have been immunized for influenza during the flu season.

Each year, CMS will evaluate the list of measures, adding new measures and, potentially, retiring existing ones. CMS will select measures that reflect consensus among affected parties and, to the extent feasible, will include measures set forth by one or more national consensus-building entities. The chart that follows provides a summary of the measures ASCs will be required to report initially, and their performance and reporting dates.

2. How will the 2% penalty be calculated and applied?

An ASC that does not successfully report data to the Medicare program by the specified 2012 deadlines will have its payments reduced by 2% in 2014. CMS will identify ASCs by their CMS Certification Number (CCN), which was formerly called the Medicare Provider Number. Beginning October 1, 2012, at least 50% of Medicare claims must contain quality data G-codes. If a facility fails to meet that requirement, CMS will reduce the 2014 ASC conversion factor for that center by 2%, causing all of the ASC’s Medicare claims to be paid at a lower rate. For example, if the conversion factor for the year is $40.00, a non-reporting ASC would start with a base rate of $39.20. That new “starting point” would then be multiplied by the relative weight for each service and adjusted by the wage index to arrive at the reimbursement Medicare will provide to that ASC.

Failure to report in subsequent years will affect future years’ payments to the same extent. For example, an ASC that fails to report in 2013 will receive reduced payments in 2015. The penalties, however, will not be cumulative. An ASC that fails to report in 2012 but successfully reports in 2013 will receive the full payment update in 2015.

3. My ASC is run by a management company. Can the corporate office report my facility’s data for me?

Generally, no. Beginning on October 1, 2012, ASCs must use quality data G-codes that Medicare released in 2012 to report the five measures that CMS selected for the initial year of the reporting program. ASCs will need to include these codes on the CMS-1500 claim forms they submit to Medicare. At this time, CMS can receive this information only when it is submitted on Medicare claims.

CMS will begin collecting information on certain quality measures in 2013 through its QualityNet web site. (Note that the web site is not yet able to accept ASC registrations.) ASCs will have to create an account on the web site and log in during specified periods of time in 2013 (see the chart included in the response to Question #1 above) to report whether or not they had a safe surgery checklist in use during Calendar Year 2012. Beginning in 2013, ASCs will also need to use this site to report the surgical volumes for specific procedures performed in 2012 on all patients (Medicare and non-Medicare). This information could be reported by an individual who is located either in a center or at a corporate headquarters as long as the ASC has authorized that person to file the report using the center’s unique access code.

4. Will Medicare evaluate our ASC’s performance based only on whether we report the data as required, or do we have to achieve certain results? In other words, will CMS penalize us if we fail to meet certain benchmarks?

For now, if you report the required data (for example, whether or not you used a safe surgery checklist any time during 2012) you will be in compliance with the ASC Quality Reporting Program and receive the full annual update to your payments. The program does not currently base payments on your performance on the quality measures.

ASCs should be aware that CMS will make these data reports available to the public. The public may form a negative perception of ASCs that do not report data or that report poor performance on the quality measures, so centers are encouraged to focus not only on reporting successfully, but also on achieving high levels of performance on each measure.

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 in the chart included in Question #1 will need to be reported using the G-codes that Medicare has provided. Your ASC will need to report these measures only for Medicare Part B fee-for-service beneficiaries (including Railroad Retirement Board). For example, no data would be submitted for a Medicare beneficiary who is enrolled in a Medicare Advantage plan. Beginning January 1, 2013, your ASC will also need to report these measures on claims where Medicare is the secondary payer.

Beginning in 2013, however, ASCs will be required to report their total—Medicare and non-Medicare—2012 surgical volume for certain specified procedures.

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. Do we report data on claims for Medicare beneficiaries if they are for non-covered services?

No. When a Medicare beneficiary has a service that is not covered by Medicare, you would not report quality data on the claim submitted for this service.

7. Should an ASC report a charge or leave the charge field blank when reporting a G-code on a claim?

G-codes must be entered on the CMS-1500 claim form and have an associated charge in order to be accepted into the CMS warehouse. These codes will populate fields 24 D and 24 F on the claim form.

• 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 quality data G-code line is denied and tracked.

8. Will my ASC receive a Remittance Advice (RA) associated with a claim that contains a G-code line-item?

ASCs will receive an RA for a claim on which the G-code is reported. The RA will include a standard remark code (N365) and a message confirming that the G-code passed into the National Claims History (NCH) file. N365 reads as follows: “This procedure code is not payable. It is for reporting/information purposes only.” The N365 remark code does not indicate whether the G-code is accurate for that claim or for the measure being reported.*

ASCs should keep track of all cases that they report using a G-code so that they can verify the G-codes that their ASC reported against the RA notice sent by their Medicare Administrative Contractor (MAC). Each G-code line-item will be listed with the N365 denial remark code.

ASCs should note that the submission of a non-zero charge amount for G-codes may complicate secondary payers’ processing of the claims. ASCs are not allowed to collect any monies from beneficiaries for charges submitted for the G-codes.

9. We forgot to put the G-codes on a claim. Can we resubmit the claim with the proper G-codes attached?

Claims may not be resubmitted for the sole purpose of adding or correcting G-codes.*

10. We submitted a claim that was denied, but the error has been corrected and we plan to resubmit the claim. Do we include the G-codes again?

If a denied claim is subsequently corrected through the appeals process involving the carrier/Medicare Administrative Contractors, G-codes should also be included on the resubmitted claim in accordance with the instructions in the measure specifications.*