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.

For reporting in 2021, there are six measures required for eligible Medicare-certified facilities* to avoid Medicare payment reductions in 2022. The deadline for submitting ASCQR Program data is May 17, 2021, due to May 15 falling on a Saturday this year. Due to the COVID-19 public health emergency exceptions granted, only data submission for encounters from July 1, 2020, through December 31, 2020, is required. Data submission for encounters from January 1, 2020, through June 30, 2020, (the excepted months) is voluntary.

*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.

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

  • 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 QualityNet. This aggregate data must be reported by all Medicare-certified ASCs, regardless of specialty or case mix. If your center does not perform colonoscopies, you will enter “0” in the numerator and the denominator for ASC-9. Data collected in 2020 must be submitted via QualityNet by May 17, 2021.

  • 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 will become publicly available.

  • 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.

  • ASC-13: Normothermia 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. Data collected in 2019 must be submitted via QualityNet by May 17, 2021.

  • ASC-14: Unplanned Anterior Vitrectomy is used to assess the percentage of cataract surgery patients who have an unplanned anterior vitrectomy. Data collected in 2019 must be submitted via QualityNet by May 15, 2020.

  • Facilities do not need to report data for ASC-17: Hospital Visits after Orthopedic 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 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.

Visit ASCA's 2021 Quality Reporting Requirements web page and the Ambulatory Surgical Center Quality Reporting Specifications Manual for more information on all measures.


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