Gina Throneberry, RN, MBA, CASC, CNOR Director of Education and Clinical Affairs Ambulatory Surgery...

CMS Quality Reporting for ASCs

Gina Throneberry, RN, MBA, CASC, CNORDirector of Education and Clinical Affairs

Ambulatory Surgery Center Association (ASCA)

Participants will:• Identify quality reporting by Centers for Medicare

& Medicaid Services (CMS) for Ambulatory Surgery Centers (ASCs)• Understand the history of quality measure

development• Learn to collect and report the data for the

required quality measures

Learning Objectives

Centers for Medicare & Medicaid Services (CMS) / State

Life Safety Code (LSC)

Occupational Safety and Health Administration (OSHA)

Food and Drug Administration (FDA)

Environmental Protection Agency (EPA)

Drug Enforcement Agency (DEA)

Federal Aviation Administration (FAA)

Regulatory Surveys

American Recovery and Reinvestment Act of 2009 Stimulus money provided the down payment for a nationwide

effort to reduce health care associated infections in stand-alone or same-day surgical centers.

Interpretive Guidelines for the Conditions for Coverage provide guidance on the meaning of the rules and further advice on how ASCs should comply.

State Operations Manual http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_l_ambulatory.pdf

Infection Control Surveyor Worksheethttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107_exhibit_351.pdf

Centers for Medicare & Medicaid Services “Medicare” Surveys

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_l_ambulatory.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_l_ambulatory.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107_exhibit_351.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107_exhibit_351.pdf

Medicare requires ASCs to comply with the 2000 edition of the Life Safety Code, updated and published by the National Fire Protection Association.

Life Safety Code Surveys

In April 2014, CMS announced the proposal to adopt the National Fire Protection Association’s (NFPA) 2012 editions of the Life Safety Code (LSC) and the Health Care Facilities Code (HCFC). ◦ The requirement is currently a 1-hour minimum separation between ASCs

and other adjacent tenants/occupancies. This proposal would require a 2-hour separation in un-sprinkled buildings.

◦ More extensive alarms, and more elaborate medical air compressors and clinical vacuum on piped medical gas systems would be required which would cause needed upgrades to systems.

◦ For windowless anesthetizing locations: “The ASC must have a supply and exhaust system that (i) Automatically vents smoke and products of combustion, (ii) Prevents recirculation of smoke originating within the surgical suite, and (iii) Prevents the circulation of smoke entering the system intake. These requirements would impact the design, installation, and operation of the entire HVAC system for a facility.

Life Safety Code Surveys

Occupational Exposure to Bloodborne Pathogens 29CFR 1910.1030

http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10051

OSHA has two different types of inspections:• Enforcement inspections determined by OSHA

(unannounced)• Consultation services that are requested by the facility

(scheduled) http://www.osha.gov/dcsp/smallbusiness/consult.htm

OSHA Surveys




http://www.osha.gov/dcsp/smallbusiness/consult.html

http://www.osha.gov/dcsp/smallbusiness/consult.html

These surveys focus on the ASC’s response to recalls.

http://www.fda.gov/Safety/Recalls/default.htm

http://www.fda.gov/Safety/MedWatch/default.htm

FDA Surveys

http://www.fda.gov/Safety/Recalls/default.htm

http://www.fda.gov/Safety/MedWatch/default.htm

Resource Conservation and Recovery Act (RCRA) gives the EPA the authority to control hazardous waste from the “cradle to the grave”. This includes the generation, transportation, treatment, storage, and disposal of hazardous waste.

Hazardous Pharmaceutical Waste under the RCRA:• Contains a “P” (acutely hazardous) or “U” (toxic) listed waste as the

sole ingredient; or• Exhibits at least one “characteristic” of a hazardous waste

It is recommended to involve the center’s consulting pharmacist to make certain the center is in compliance with federal and state regulations.

EPA Surveys

Questions and Answers regarding DEA 222 forms- http://www.deadiversion.usdoj.gov/faq/dea222.htm

DEA Surveys

http://www.deadiversion.usdoj.gov/faq/dea222.htm

http://www.deadiversion.usdoj.gov/faq/dea222.htm

These surveys examine:• the process of transporting radioactive materials• training of ASC staff in handling radioactive

materials• the ASC’s policies on radioactive materials (process

for shipping of materials, process for return of product, how to handle hazards, staff training, consultant physicist, etc.)

FAA Surveys

Rule Reference Proposed or Final Rule

Federal Register (FR) Referencehttps://www.federalregister.gov Program Highlights

CY 2015 OPPS/ASC

Final 1 new claims-based measure- “dry run” 2015

CY 2014OPPS/ASC

Final 78 FR 75122 Finalized 3 measures

CY 2013OPPS/ASC

Final 77 FR 68492 No additional measures

FY 2013IPPS/LTCH PPS

Final 77 FR 53637 Finalized requirements

CY 2012OPPS/ASC

Final 76 FR 74492 Finalized 8 measures

CY 2011OPPS/ASC

Final 75 FR 72109 Discussed/Not implemented

CY 2010OPPS/ASC


CY 2009OPPS/ASC


CY 2008OPPS/ASC


ASCQR Program Rule History

https://www.federalregister.gov/

ASCQR Program Measures Summary

Number Measure Title Type of Measure

Data Collection Date

Data Reporting Date

Affected Groups

ASC-1 Patient Burn Claims-Based January 1- December 31,

2014

January 1- December 31,

2014

Medicare Part B fee for service patients

ASC-2 Patient Fall Claims-Based January 1- December 31,

2014


2014


ASC-3 Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure,Wrong Implant

Claims-Based January 1- December 31,

2014


2014


ASC-4 Hospital Transfer/Admission


2014


2014


ASC-5 Prophylactic Intravenous (IV) Antibiotic Timing


2014


2014


ASC-6 Safe Surgery Checklist Use Web-Based via QualityNet

secure portal


2014

January 1- August 15, 2015

All patients

ASC-7 ASC Facility Volume Data on Selected ASC Surgical Procedures

Web-Based via QualityNet

secure portal


2014


All patients

ASC-8 Influenza Vaccination Coverage among Healthcare Personnel

Web-Based via NHSN

October 1, 2014- March 31, 2015

through May 15, 2015

Health Care Personnel

ASCQR Program Measures Summary

Number Measure Title Type of Measure

Data Collection Date

Data Reporting Date

Affected Groups

ASC-9 Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients


secure portal

April 1-December 31,

2014


Sampling

ASC-10 Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use


secure portal

April 1- December 31,

2014


Sampling

ASC-11 Voluntary Cataracts- Improvement in Patient’s Visual Function within 90 days following Cataract Surgery


secure portal

January 1,- December 31,

2015

January 1, August 15, 2016

Sampling

ASC-12 Facility Seven-Day Risk Standardized Hospital Visit Rate after Outpatient Colonoscopy

Claims-Based Paid Medicare Fee for Service

Claims from January 1, 2016 – December 31,

2016

Paid Medicare Fee for Service

Claims from January 1, 2016 –

December 31, 2016

Paid Medicare Fee for Service Claims

CMS ASC Quality Reporting Program Quality Measures Specifications Manual To date- 9 versions (April 2012-June 2014) Latest version- 4.0 (June 2014)

• Located @ www.qualitynet.org under ASC tab• Included in this manual:

Measure specifications Data collection and submission Quality Data Codes (QDCs)

CMS Ambulatory Surgical Center Quality Reporting Program

http://www.qualitynet.org/

ASC-1: Patient Burn*• ASC-2: Patient Fall*• ASC-3: Wrong Site, Wrong Side, Wrong

Patient, Wrong Procedure, Wrong Implant*• ASC-4: Hospital Transfer/Admission*• ASC-5: Prophylactic Intravenous (IV)

Antibiotic Timing*

*Data submission began in CY 2012

ASC Quality Reporting Program

Claims Based Reporting–Quality Data Codes (QDCs)• Patient Burn• Patient Fall• Wrong Site, Side, Patient, Procedure, Implant• Hospital Admission/Transfer• Prophylactic IV Antibiotic Timing

Web Based Reporting via QualityNet Secure Portal (www.qualitynet.org) • Safe Surgery Check List Use• ASC Volume of Selected Procedures for all-patients

Web Based Reporting Via Centers for Disease Control and Prevention (CDC) National Health Care Safety Network (NHSN) (www.cdc.gov/nhsn/index.html) • Influenza Vaccination Coverage Among Health Care Personnel

How Will the Data be Reported?


http://www.cdc.gov/nhsn/index.html

The ASC quality measures, G codes, and their descriptions are included in Table 6 below:ASC Quality Measures G-code Long Descriptor

G8907

Patient documented not to have experienced any of the following events: a burn prior to discharge; a fall within the facility; wrong site/side/patient/procedure/implant event; or a hospital transfer or hospital admission upon discharge from the facility.

Patient burn G8908 Patient documented to have received a burn prior to dischargeG8909 Patient documented not to have received a burn prior to discharge

Patient fall in ASC facility G8910 Patient documented to have experienced a fall within ASC

G8911Patient documented not to have experienced a fall within Ambulatory Surgical Center

Wrong site, wrong side, wrong patient, wrong procedure, wrong implant G8912

Patient documented to have experienced a wrong site, wrong side, wrong patient, wrong procedure or wrong implant event

G8913Patient documented not to have experienced a wrong site, wrong side, wrong patient, wrong procedure or wrong implant event

Hospital transfer/Admission G8914Patient documented to have experienced a hospital transfer or hospital admission upon discharge from ASC

G8915Patient documented not to have experienced a hospital transfer or hospital admission upon discharge from ASC

Timing of Prophylactic antibiotic administration for SSI prevention G8916

Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis, antibiotic initiated on time

G8917Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis, antibiotic not initiated on time

G8918Patient without preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis

Released August 2012 The final rule can be accessed at (

https://s3.amazonaws.com/public-inspection.federalregister.gov/2012-19079.pdf)

This is the vehicle for rulemaking on the specifics of the ASC quality reporting program; ASC information begins on page 1534; Section E.◦ Participation in the ASC Quality Reporting Program; Page 1540◦ Limited details for public reporting of data; Page 1541◦ Data completeness and validation; Page 1548◦ Extraordinary circumstances; Page 1554◦ Reconsideration and appeals process; Page 1558

Inpatient/Long Term Care Hospital Prospective Payment System (IPPS) Final Rule

https://s3.amazonaws.com/public-inspection.federalregister.gov/2012-19079.pdf

https://s3.amazonaws.com/public-inspection.federalregister.gov/2012-19079.pdf

Once an ASC submits any quality measure data, the center would be considered participating

The ASC will continue to be considered a participant, regardless of whether the ASC continues to submit quality measure data, until formally withdrawing from the program

An ASC that wishes to withdraw from the ASC Quality Reporting (ASCQR) Program must fill out an online withdrawal form:• Located on the QualityNet website www.qualitynet.org• Click on left hand side: how to participate then• Click on left hand side: how to withdraw

An ASC can withdraw at any time up to August 31 prior to the payment determination year

An ASC that withdraws will incur a 2% reduction in its Annual Payment Update (APU) and any subsequent year the ASC is not participating

Participation and Non Participation


Process was established in the FY 2013 IPPS/LTCH PPS final rule (77 FR 53642 through 53643)

CMS may grant a waiver or extension to ASCs for data submission requirements if it is determined that a systemic problem with a data collection system directly or indirectly affects the ability to enter data

Needs to be submitted within 45 days of the extraordinary circumstance

Form (Extraordinary Circumstances) is located on www.qualitynet.org; click on ASC tab; form is located on the left side of the page

In the future this process will be referred to as the Extraordinary Circumstances Extensions or Exemptions Process

Extraordinary Circumstances Extension/ Waiver Process


Process was established in the FY 2013 IPPS/LTCH PPS final rule (77 FR 53643 through 53644)

Reconsideration request form must be submitted by March 17 of the affected payment year

CMS intends to complete any reconsideration reviews and communicate results within 90 days following the deadline (March 17 of the affected payment year)

Form (Annual Payment Update (APU) reconsideration) is located on www.qualitynet.org; click on ASC tab; form is located on the left side of the page

Reconsideration Process


ASC-1: Patient Burn ASC-2: Patient Fall ASC-3: Wrong Site, Wrong Side, Wrong Patient,

Wrong Procedure, Wrong Implant ASC-4: Hospital Transfer/Admission ASC-5: Prophylactic Intravenous (IV) Antibiotic Timing ASC-6: Safe Surgery Checklist Use ASC-7: ASC Facility Volume Data on Selected ASC

Surgical Procedures {Procedure Category Corresponding HCPCS Codes: Eye/Gastrointestinal/Genitourinary/Musculoskeletal/ Nervous/Respiratory/Skin/Multi-system}

ASC Quality Reporting Program

Safe Surgery Checklist Use Intent: Assess whether an ASC uses a safe surgery

checklist May employ any checklist as long as it addresses

effective communication and safe surgery practices in each of three peri-operative 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 Applies to all ASCs

Measure Details

Safe Surgery Checklist Use Data collection: January 1-December 31, 2014 For 2014 and beyond, the checklist should be

utilized for the ENTIRE year for an answer of "Yes".

Report “Yes” or “No” on the Quality Net web site (www.qualitynet.org) between January 1 through August 15, 2015.

Measure Details


ASC Volume of Selected Procedures Intent: Measure all patient volume of procedures performed in one of

eight categories• Eye• Gastrointestinal• Genitourinary• Musculoskeletal • Nervous System• Respiratory• Skin• Multi-system

Measurement from January 1, 2014 through December 31, 2014 Report volumes for entire 2014 calendar year on the QualityNet web

site (www.qualitynet.org) between January 1 thru August 15, 2015

Measure Details


Organ System CMS Procedure Category Surgical Procedure CodesEye Organ transplant (eye) 65756, V2785

Laser procedure of eye 65855, 66761, 66821

Glaucoma procedures 66170, 66180 , 66711

Cataract procedures 66982, 66984

Injection of eye 67028, J2778, J3300, J3396

Retina, macular and posterior segment procedures 67041, 67042, 67210, 67228

Repair of surrounding eye structures 15823, 67900, 67904, 67917, 67924

Gastrointestinal GI endoscopy procedures 43239, 43235, 43248, 43249, 43251, 44361, 45330, 45331, 45378, 45380, 45381, 45383, 45384, 45385 ,46221

Swallowing tube (esophagus) 43450

Hernia repair 49505

GI screening procedures G0105, G0121

Organ System CMS Procedure Category Surgical Procedure Codes

Genitourinary Kidney stone fragmentation 50590

Bladder related procedures 52000, 52005, 52204, 52281, 52310, 52332

Prostate biopsy 55700

Radiologic procedures (GU) 74420

Ultrasound procedures (GU) 76872

Musculoskeletal Joint or muscle aspiration or injection 20610

Removal of musculoskeletal implants 20680

Repair of tendons and ligaments 23412

Repair of foot, toes, fingers, and wrist 26055, 28270, 28285, 28296, 29848

Removal of musculoskeletal lesion 26160

Joint arthroscopy 29824, 29826, 29827, 29880, 29881 , 29823, 29822

Musculoskeletal drug injection J0585, J0878, J0131

Organ System CMS Procedure Category Surgical Procedure Codes

Nervous Injection procedures in or around the spine 62310, 62311, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64622, 64623, 64626, 64627, 64633, 64634, 64635, 64636, 64640, G0260 , J2278

Device implant 63650

Nerve decompression 64718

Repair of foot, toes, fingers, and wrist 64721

Respiratory Sinus procedure 30140, 31255, 31267

Skin Skin procedures including debridement, reconstructive, wound closure, excision and/or repair

11042, 13132, 14040, 14060, 15260, 17311, Q4101, Q4102, Q4106

Multi-system* Brachytherapy Cancer treatment with angiogenesis inhibitor

*Multi-System: procedures that can be performed in more than one organ system.

C2638, C2639, C2640, C2641 C9257


No reporting for these two measures for 2013 Data Collection for these two measures will

resume January 1 - December 31, 2014 Data Reporting for calendar year 2014 will be

from January 1- August 15, 2015



ASC Program Measurement Set for the CY 2016 Payment Determination ASC-1: Patient Burn ASC-2: Patient Fall ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure,

Wrong Implant ASC-4: Hospital Transfer/Admission ASC-5: Prophylactic Intravenous (IV) Antibiotic Timing ASC-6: Safe Surgery Checklist Use ASC-7: ASC Facility Volume Data on Selected ASC Surgical Procedures

{Procedure Category Corresponding HCPCS Codes: Eye/Gastrointestinal/Genitourinary/Musculoskeletal/ Nervous/Respiratory/Skin/Multi-system}

ASC- 8: Influenza Vaccination Coverage among Healthcare Personnel * *New measure for CY 2016 payment determination

Measures for ASCs

Influenza Vaccination Coverage among Healthcare Personnel (HCP) Intent: assess the percentage of HCP immunized for influenza

during the flu season 3 Categories of Healthcare Personnel will include:• Employee on facility payroll• Licensed independent practitioners, e.g. physicians (MDs, DO), advance

practice nurses and physician assistants who are affiliated with the facility who do not receive a direct paycheck from the facility

• Adult students/trainees and volunteers who do not receive a direct paycheck from the facility

Measure Details

Data collection begins with immunizations for the flu season October 1, 2014 through March 31, 2015

CDC’s NHSN website for enrollment: www.cdc.gov/nhsn/ambulatory-surgery/enroll.html

◦“NHSN facility administrator enrollment guide” (step by step)

Deadline for data submission for the 2014-2015 flu season through May 15, 2015.

Influenza Vaccination Coverage among Healthcare Personnel (HCP)

http://www.cdc.gov/nhsn/ambulatory-surgery/enroll.html

The NHSN Website: http://www.cdc.gov/nhsn

Select ‘new to NHSN’

http://www.cdc.gov/nhsn

Click on Ambulatory Surgery Centers

NHSN: Five Step Enrollment Process

Review and accept the NHSN rules of behavior

Register with SAMS SAMS = Secure Access Management

Services, a federal information technology (IT) system that gives authorized personnel secure access to non-public CDC applications

Enrollment Steps

Users must fax or mail notarized proof of identity to CDC.

You will receive a grid card in the mail in order to access NHSN.

Complete and submit required forms (facility information, facility survey, consent form)

Reporting (https://sams.cdc.gov ) user authorization through Secure Access Management Services (SAMS) is required for access to NHSN.

Secure Access Management Services (SAMS)

https://sams.cdc.gov/

Employee HCP Non-Employee HCP

Employees (staff on facility payroll)

Licensed independent practitioners:

Physicians, advanced practice nurses, &

physician assistants

Adult students/ trainees & volunteers

Other contract personnel

1. Number of HCP who worked at this healthcare facility for at least 1 day between October 1 and March 31

2. Number of HCP who received an influenza vaccination at this healthcare facility since influenza vaccine became available this season

3. Number of HCP who provided a written report or documentation of influenza vaccination outside this healthcare facility since influenza vaccine became available this season

4. Number of HCP who have a medical contraindication to the influenza vaccine

5. Number of HCP who declined to receive the influenza vaccine

6. Number of HCP with unknown vaccination status (or criteria not met for questions 2-5 above

Influenza Vaccination Summary

Employee HCP Non-Employee HCP: Licensed independent

practitioners (physicians, advance practice nurses, and physician assistants)

Non-Employee HCP: Adult students/trainees and volunteers

41

Denominator Categories

Influenza vaccinations◦ Received at this

healthcare facility◦ Received elsewhere

Medical contraindications

Declinations Unknown status

Numerator Categories

Notes on Reporting – Example

10 + 20 + 15 + 5 + 5 = 55 70 + 10 + 10 + 5 + 5 = 100 20 + 2 + 1 + 1 + 1 = 25

The CDC conducted live training webinars in August to cover the requirements for collecting and entering HCP influenza vaccination summary data.

A recording of the webinar has been posted at: http://www2.cdc.gov/vaccines/ed/nhsn/, so staff can review the recorded training and slides.

For questions on HCP influenza vaccination summary reporting, please send an e-mail to: [email protected] and include “HPS Flu Summary-ASC” in the subject line.

Training Webinars for NHSN

http://www2.cdc.gov/vaccines/ed/nhsn/

mailto:[email protected]

Released on November 27, 2013 www.gpo.gov/fdsys/pkg/FR-2013-12-10/pdf/2013-2

8737.pdf• ASC Quality Reporting Program begins on page 974 ;

Section XV. Requirements for ASC Quality Reporting Program

• 3 Quality Measures for CY 2016: page 979• 50% minimum reporting threshold: page 1025• Exempting low volume providers: page 1027

(less than 240 Medicare claims/year)

2014 Medicare Hospital Outpatient Prospective Payment System (OPPS)/ASC Payment Final Rule

http://www.gpo.gov/fdsys/pkg/FR-2013-12-10/pdf/2013-28737.pdf


Previous ASC 1- ASC 8 plus 3 Additional Measures:• Endoscopy/Poly Surveillance: Appropriate follow-up interval

for normal colonoscopy in average risk patients (NQF #0658);• Endoscopy/Poly Surveillance: Colonoscopy Interval for

Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use (NQF #0659); and

• Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery (NQF #1536).

* NQF= National Quality Forum (www.qualityforum.org)

New ASC Measures for CY 2016 and Subsequent Payment Determination Years

http://www.qualityforum.org/

Denominator: patients aged 50 years and older receiving screening colonoscopy without biopsy or polypectomy

Numerator: patients who had a recommended follow- up interval of 10 years for repeat colonoscopy documented in their colonoscopy report*

*follow-up interval is at least 10 years from the date of the current colonoscopy *physician’s documentation in the colonoscopy report

ASC 9: Endoscopy/Polyp Surveillance: Normal Colonoscopy

Exclusions: documentation of medical reasons for not recommending at least a 10-year follow-up (above average risk, inadequate prep)

Inclusions:Patients aged ≥ 50 on date of encounter And ICD-9-CM Diagnosis code: V76.51 And CPT or HCPCS: 45378, G0121 WithoutCPT Category I Modifiers: 52, 53, 73, 74 Without ICD-9-CM Diagnosis codes: V18.51, V12.72, V16.0, V10.05

(The ICD-9 codes will be updated when the conversion to ICD-10 occurs)

ASC 9: Endoscopy/Polyp Surveillance: Normal Colonoscopy

Denominator: number of patients 18 years and older receiving a surveillance colonoscopy with a history of a prior colonic polyp in a previous colonoscopy

Numerator: number of patients who had an interval of three or more years since their last colonoscopy*

*Information regarding performance interval can be obtained from the medical record.

ASC 10: Endoscopy/Polyp Surveillance: Adenomatous Polyp

Exclusions: • Documentation of medical reason(s) for an interval of

less than three years since the last colonoscopy (for example, last colonoscopy incomplete, last colonoscopy had inadequate prep, piecemeal removal of adenomas, or last colonoscopy found greater than 10 adenomas) • Documentation of a system reason(s) for an interval

less than three years since last colonoscopy (for example, unable to locate previous colonoscopy report, previous colonoscopy report was incomplete)


Inclusions:Patients aged ≥ 18 years on date of encounter AndDiagnosis for history of colonic polyp(s) (ICD-9-CM): V12.72, V10.05 AndCPT or HCPCS: 44388, 44389, 44392, 44393, 44394, 45355, 45378, 45380, 45381, 45383, 45384, 45385, G0105 Without CPT Category I Modifiers: 52, 53, 73 or 74

(The ICD-9 codes will be updated when the conversion to ICD-10 occurs)


Denominator: number of patients aged 18 years and older in sample who had cataract surgery and completed both a pre-operative and post-operative visual function instrument

Numerator: number of patients 18 years and older who had improvement in visual function achieved within 90 days following cataract surgery, based on completing both a pre-operative and post-operative visual function instrument

ASC 11: Cataract: Improvement in Patients Visual Function within 90 days Voluntary

Examples of tools for visual function assessment include, but are not limited to: National Eye Institute-Visual Function Questionnaire – VFQ-25

www.rand.org/health/surveys_tools/vfq.html Visual Function (VF)-14

www.med.teikyo-u.ac.jp/~ortho/med/reh/VF-14.html Modified VF-8

http://ascrs.org/sites/default/files/resources/2013%20Cataracts%20Measures%20Group%20Post-Surgery%20VF-8R_0.pdf Modified Catquest-9

http://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/OPX/A/OPX_90_8_2013_04_04_LUNDSTROM_201940_SDC1.pdf

ASC 11: Cataract: Improvement in Patients Visual Function within 90 days

http://www.rand.org/health/surveys_tools/vfq.html

http://www.med.teikyo-u.ac.jp/~ortho/med/reh/VF-14.html

http://ascrs.org/sites/default/files/resources/2013%20Cataracts%20Measures%20Group%20Post-Surgery%20VF-8R_0.pdf

http://ascrs.org/sites/default/files/resources/2013%20Cataracts%20Measures%20Group%20Post-Surgery%20VF-8R_0.pdf




55

http://www.oqrsupport.com/asc/tools Resources and tools for endoscopy and cataract measures

http://www.oqrsupport.com/asc/tools

Population Per Year 0-900Yearly Sample Size 63Quarterly Sample Size 16Monthly Sample Size6

Population Per Year ≥901Yearly Sample Size 96Quarterly Sample Size 24Monthly Sample Size8

Sampling Size SpecificationsASC-9, ASC-10, or ASC-11-voluntary


Web Based Reporting via QualityNet Secure Portal (www.qualitynet.org)• Safe Surgery Check List Use• ASC Volume of Selected Procedures for all-patients


Web Based Reporting via QualityNet Secure Portal (www.qualitynet.org)• Endoscopy/Polyp Surveillance (normal)• Endoscopy/Polyp Surveillance (adenomatous)• Cataract: improvement in visual function- voluntary





Released on October 31, 2014• http://www.ofr.gov/(S(j4muxl5s4vqongwcshdlh533))/

OFRUpload/OFRData/2014-26146_PI.pdf• ASC Quality Reporting Program begins on page 781:

Section XIV. Requirements for ASC Quality Reporting Program

2015 Medicare Hospital Outpatient Prospective Payment System (OPPS)/ASC Payment Final Rule

http://www.ofr.gov/(S(j4muxl5s4vqongwcshdlh533))/OFRUpload/OFRData/2014-26146_PI.pdf


Previous ASC 1- ASC 10 plus ASC 11: Cataracts: Improvement in Patient’s Visual

Function within 90 Days Following Cataract Surgery (NQF #1536) voluntary

NQF = National Quality Forum (www.qualityforum.org)



Previous ASC 1- ASC 10 plus ASC 11: Cataracts: Improvement in Patient’s Visual

Function within 90 Days Following Cataract Surgery (NQF #1536) voluntary

1 Additional Measure: ASC 12: Facility Seven-Day Risk-Standardized Hospital

Visit Rate after Outpatient Colonoscopy

NQF = National Quality Forum (www.qualityforum.org)



Claims based measure No additional data submission from ASCs The measure outcome is all unplanned hospital

visits (admissions, observation stays, and emergency department [ED] visits) within 7 days of the procedure.

ASC 12: Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy

In 2015, Medicare will perform a “dry run” of this measure.

A dry run is a preliminary analysis of data in which ASCs may review their measure results, and ask questions about and become familiar with the measure methodology.

The most recent complete claims samples (usually 6-9 months prior to the start date) for dry runs will be used.


The dry run will generate confidential reports at the patient level, indicating whether the patient had a hospital visit, the type of visit (admission, ER visit, or observational stay), the admitting facility, and the principal discharge diagnosis.

The ASC will have the opportunity to receive individual patient data and information contained within individual patient records in order to identify performance gaps and develop quality improvement strategies.

Dry runs results ARE NOT linked to public reporting or payment determinations.

ASCs can review their confidential dry run reports at www.qualitynet.org.



For the CY 2018 payment determination, paid Medicare Fee For Service claims from January 1 – December 31, 2016 will be used (calendar years 2 years before the payment determination calendar year.


Patient experience of care: ASC Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient experience survey

Care Plan- (percentage of patients 65 years and older who have a care plan or surrogate decision documented in the medical record)

Hair removal Normothermia Unplanned anterior vitrectomy

Measures Under Consideration (MUC) List

ASC Quality Collaboration website (measure summary and implementation guide)http://ascquality.org/qualitymeasures.cfm

Ambulatory Surgery Center Association (ASCA) http://www.ascassociation.org

QualityNet website (CMS Specifications Manual & Email Notifications)

http://qualitynet.org

FMQAI website (CMS national support contractor)http://oqrsupport.org

CMS certification number (CCN) Look-Up Tool (allows a facility to enter its National Provider Identifier (NPI) in the search box to find its CCN)

http://www.oqrsupport.com/asc/ccn

Websites with Additional Information

http://ascquality.org/qualitymeasures.cfm



http://www.ascassociation.org/

http://qualitynet.org/

http://qualitynet.org/

http://oqrsupport.org/



Contact FMQAI for Program Questions at [email protected] or via phone (866) 800-8756 Monday through Friday,7 a.m. to 6 p.m. Eastern Time

Contact the QualityNet Help Desk for Technical Issues at [email protected] via phone (866) 288-8912 Monday through Friday, 7 a.m. to 7 p.m. Central Time

Additional Questions



Federal Register / Vol. 76, No. 230 / Wednesday, November 30, 2011 / Rules and Regulations. Available at http://www.gpo.gov/fdsys/pkg/FR-2011-11-30/pdf/2011-28612.pdf

Federal Register / Vol. 77, No. 170 / Friday, August 31, 2012/ Rules and Regulations. Available at http://www.gpo.gov/fdsys/pkg/FR-2012-08-31/pdf/2012-19079.pdf

Federal Register / Vol. 77, No. 221 / Thursday, November 15, 2012 / Rules and Regulations. Available at http://www.gpo.gov/fdsys/pkg/FR-2012-11-15/pdf/2012-26902.pdf

Federal Register / Vol. 78, No. 237 / Tuesday, December 10, 2013/ Rules and Regulations. Available at http://www.gpo.gov/fdsys/pkg/FR-2013-12-10/pdf/2013-28737.pdf

Federal Register / Vol. 79, No. 134 / Monday, July 14, 2014/ Rules and Regulations. Available at http://www.gpo.gov/fdsys/pkg/FR-2014-07-14/pdf/2014-15939.pdfASC Quality Collaboration Implementation Guide, Version 2.1, April 2014. Available at http://ascquality.org/documents/ASCQC.Implementation.Guide.2.1April2014.pdf

CMS ASC Quality Reporting Program Quality Measures Specifications Manual, Version 4.0, June 2014. Available at www.qualitynet.org

Quality Net at www.qualitynet.org National Healthcare Safety Network www.cdc.gov/nhsn/ http://www.ofr.gov/(S(j4muxl5s4vqongwcshdlh533))/OFRUpload/OFRData/2014-26146_PI.pdf

References









http://ascquality.org/documents/ASCQC.Implementation.Guide.2.1April2014.pdf



http://www.cdc.gov/nhsn/



Gina Throneberry, RN, MBA, CASC, CNORAmbulatory Surgery Center Association (ASCA)

Director or Education and Clinical Affairs [email protected]

Questions/Comments


Gina Throneberry, RN, MBA, CASC, CNOR Director of Education and Clinical Affairs Ambulatory Surgery...

Documents

Transcript of Gina Throneberry, RN, MBA, CASC, CNOR Director of Education and Clinical Affairs Ambulatory Surgery...