cms quality measure repor6ng update...asc-14 unplanned anterior vitrectomy december 31, web-based...

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Keeping you “in the know” in the ASC industry

CMSQualityMeasureRepor6ngUpdate

GinaThroneberry,RN,MBA,CASC,CNORDirectorofEduca6onandClinicalAffairs

AmbulatorySurgeryCenterAssocia6on(ASCA)

ASCQRProgramMeasuresSummary

Number MeasureTitle TypeofMeasure

DataCollectionDates

DataReportingDates

PaymentDetermination

Year

MeasureApplies

To

ASC-1 PatientBurn Claims-Based January1-December31,2017

January1-December31,2017

CY2019 MedicarePartBfeeforservicepatients



CY2020

ASC-2 PatientFall Claims-Based January1-December31,2017





CY2020

ASC-3 WrongSite,WrongSide,WrongPatient,WrongProcedure,WrongImplant

Claims-Based January1-December31,2017





CY2020

ASC-4 HospitalTransfer/Admission






CY2020

ASC-5 ProphylacticIntravenous(IV)AntibioticTiming



Noreportingin2018

MeasureremovedforCY2019

MedicarePartBfeeforservicepatients

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DataCollectionDates

DataReportingDates


Year

MeasureAppliesTo

ASC-6 SafeSurgeryChecklistUse

Web-BasedviaQualityNetsecureportal


January1-May15,2018Noreportingin

2018

MeasureRemovedforCY2019

Allpatients

ASC-7 ASCFacilityVolumeDataonSelectedASCSurgicalProcedures



January1-May15,2018Noreportingin

2018

MeasureRemovedforCY2019

Allpatients

ASC-8 InfluenzaVaccinationCoverageamongHealthcarePersonnel

Web-BasedviaNationalHealthcare

SafetyNetwork(NHSN)

October1,2017March31,2018

ThroughMay15,2018

CY2019 HealthCarePersonnel

October1,2018March31,2019

ThroughMay15,2019

CY2020 HealthCarePersonnel



DataCollectionDates

DataReportingDates


Year

MeasureApplies

ToASC-9 Endoscopy/PolypSurveillance:

AppropriateFollow-UpIntervalforNormalColonoscopyinAverageRiskPatients



January1-May15,2018 CY2019 Sampling


January1-May15,2019 CY2020

ASC-10 Endoscopy/PolypSurveillance:ColonoscopyIntervalforPatientswithaHistoryofAdenomatousPolyps–AvoidanceofInappropriateUse






ASC-11Voluntary

Cataracts-ImprovementinPatient’sVisualFunctionwithin90daysfollowingCataractSurgery






ASC-12 FacilitySeven-DayRiskStandardizedHospitalVisitRateafterOutpatientColonoscopy

AdministrativeClaims-Based

PaidMedicareFeeforServiceClaims

January1-December31,2017andsubsequent

years

PaidMedicareFeeforServiceAdministrative

ClaimsPreviewReportswereavailableforreviewon

QualityNet

CY2019 PaidMedicareFeeforServiceClaims



DataCollectionDates

DataReportingDates


Year

MeasureApplies

To

ASC-13 Normothermia Web-basedviaQualityNetsecureportal

January1-December31,

2018

January1-May15,2019

CY2020 Sampling

ASC-14 UnplannedAnteriorVitrectomy

Web-basedviaQualityNetsecureportal


2018

January1-May15,2019

CY2020 AllPatientsMeetingCriteria

ASC-15(15a-e)

OutpatientandAmbulatorySurgeryConsumerAssessmentofHealthcareProvidersandSystems(OASCAHPS

SurveyAdministered

byanapprovedvendor


2018Delayed

QuarterlybyCMSapproved

vendor

CY2020Delayed

AllPatientswithExclusions300CompletedSurveysviaApprovedVendor

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DataCollectionDates

DataReportingDates


Year

MeasureApplies

To

ASC-16NotFinalized

ToxicAnteriorSegmentSyndrome(TASS)

Web-basedviaQualityNetsecureportal


2019

January1-May15,2020

CY2021 AllPatientsMeetingCriteria

ASC-17Final

HospitalVisitAfterOrthopedicAmbulatorySurgeryProcedures

AdministrativeClaimsBased




Claims


ASC-18Final

HospitalVisitAfterUrologyAmbulatorySurgeryProcedures

AdministrativeClaimsBased




Claims


CMSAmbulatorySurgicalCenterQualityRepor6ngProgram

•  CMSASCQualityRepor6ngProgramQualityMeasuresSpecifica6onsManual•  Verifyyouhavethelatestversions

–  7.0a 1Q18-4Q18(released12/8/17)–  6.0a 1Q17-4Q17

•  [email protected]•  Includedinthismanual:

•  Measurespecifica6ons•  Datacollec6onandsubmission•  QualityDataCodes(QDCs)

ASCQualityRepor6ngProgramMeasures

•  ASC-1:Pa6entBurn•  ASC-2:Pa6entFall•  ASC-3:WrongSite,WrongSide,WrongPa6ent,Wrong

Procedure,WrongImplant•  ASC-4:HospitalTransfer/Admission•  ASC-5:Prophylac6cIntravenous(IV)An6bio6cTiming(norepor6ngin2018)

MedicarePartBFeeforServicePa1entsClaimsBasedRepor6ng–QualityDataCodes(QDCs)

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•  ASC-6:SafeSurgeryChecklistUse(norepor6ngin2018)•  ASC-7:ASCFacilityVolumeDataonSelectedASCSurgicalProcedures

(norepor6ngin2018)•  ASC-9:Endoscopy/PolypSurveillance:AppropriateFollow-UpIntervalforNormal

ColonoscopyinAverageRiskPa6ents•  ASC-10:Endoscopy/PolypSurveillance:ColonoscopyIntervalforPa6entswithaHistory

ofAdenomatousPolyps-AvoidanceofInappropriateUse

WebBasedRepor;ngviaQualityNetSecurePortal(www.qualitynet.org)•  Datacollec%on:January1throughDecember31,2017•  Datarepor%ng:January1throughMay15,2018

•  Datacollec%on:January1throughDecember31,2018•  Datarepor%ng:January1throughMay15,2019


ASC-8:InfluenzaVaccina6onCoverageamongHealthcarePersonnel

WebBasedRepor;ngViaCentersforDiseaseControlandPreven;on(CDC)Na;onalHealthCareSafetyNetwork(NHSN)(www.cdc.gov/nhsn/index.html)

•  Datacollec%onbeginswithimmuniza6onsforthefluseason

October1,2017throughMarch31,2018•  Deadlinefordatarepor%ngforthe2017-2018fluseasonisMay

15,2018.

ASCQualityRepor6ngProgramMeasuresASC-8:InfluenzaVaccina6onCoverageamongHealthcarePersonnel

•  InDecember2017NHSNusersneededtoacceptanupdatedNHSNAgreementtoPar6cipateandConsent,evenifyouhadsubmigedonepreviously.

•  ThisnewformshouldhavebeensubmigedelectronicallythroughNHSN.•  Yourfacility’sprimarycontactwasrequiredtoacceptthenewformby

April14,2018oryouwouldnotbeabletosubmitdatainNHSNforASC-8.•  NHSNfunc6onalitywillbedisabledun6ltheconsentformisacceptedby

yourfacility’sprimarycontact.

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ASC-12:FacilitySeven-DayRisk-StandardizedHospitalVisitRateajerOutpa6entColonoscopy•  DataispulledbyCMSfromtheMedicareFeeforService

administra1veclaimsthatwerebilledbythecenterstar6ngJanuary1-December31,2016andsubsequentyears.

•  Nodatasubmissionorrepor6ngrequiredfromtheASC•  ColonoscopyClaimsDetailReports(CDR)willbeperiodically

uploadedtotheQualityNetsecureportalthroughouttheyear.

•  ASC13NormothermiaOutcomeDatasubmigedforaSamplingthatmeetthedenominatorcriteria.

•  ASC14UnplannedAnteriorVitrectomy DatasubmigedforAllPa%entsthatmeetthedenominator

criteria.WebBasedRepor;ngviaQualityNetSecurePortal(www.qualitynet.org)

•  Datacollec%on:January1throughDecember31,2018•  Datarepor%ng:January1throughMay15,2019


ASC13:NormothermiaOutcome

Numerator:Surgerypa6entswithabodytemperatureequaltoorgreaterthan96.8Fahrenheit/36CelsiusrecordedwithinfijeenminutesofArrivalinPACU

Denominator:Allpa6ents,regardlessofage,undergoingsurgicalproceduresundergeneralorneuraxialanesthesiaofgreaterthanorequalto60minutesdura6on

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ExamplesofSampleSizeASC-9,ASC-10,andASC-13

Popula;onPerYear0-900YearlySampleSize 63

Popula;onPerYear≥901 YearlySampleSize 96Foreachmeasureusethedenominator/popula6ontocalculatethesamplesize.

ASC14:UnplannedAnteriorVitrectomy

Numerator:Allcataractsurgerypa6entswhohadanunplannedanteriorvitrectomy

Denominator:Allcataractsurgerypa6entsNumeratorExclusions:NoneDenominatorExclusions:None

ASC14:UnplannedAnteriorVitrectomy

Defini;ons:Admission:comple6onofregistra6onuponentryintothefacilityCataractsurgery:forpurposesofthismeasure,CPTcode66982(Cataractsurgery,complex),CPTcode66983(Cataractsurgeryw/IOL,1stage)andCPTcode66984(Cataractsurgeryw/IOL,1stage)Unplannedanteriorvitrectomy:ananteriorvitrectomythatwasnotscheduledatthe6meofthepa6ent'sadmissiontotheASC

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Thefivesurvey-basedmeasures(ASC-15a-e)arecollectedviaonesurvey{OASCAHPS}:

●ASC-15a:AboutFacili6esandStaff;●ASC-15b:Communica6onAboutProcedure;●ASC-15c:Prepara6onforDischargeandRecovery●ASC-15d:OverallRa6ngofFacility;and●ASC-15e:Recommenda6onofFacilityDatacollec6onofthesemeasureshasbeendelayed.

ASC15:Outpa6ent/AmbulatorySurgeryConsumerAssessmentofHealthcareProvidersandSystems(OASCAHPS)

•  OfficialOASCAHPSwebsitehgps://oascahps.org/(Thisistheofficialwebsitefornews,trainingandinforma1onabouttheOASCAHPSsurvey.)

•  Thesurveyhasthreeadministra6onmethods:–mail-only;–telephone-only;and–mixedmode(mailwithtelephonefollow-upofnon-respondents)•  Toll-freenumber:1-866-590-7468forques6ons

ASC15:OASCAHPSSurveyWebsite

•  ThesurveyinstrumentbecameavailableforvoluntaryuseinJanuary2016andcanbelocatedathgps://oascahps.org/Survey-Materials

•  Pages12-14oftheguide“AmbulatorySurgeryCenters’Responsibili6es”

ASC15:OASCAHPSSurveyWebsite

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•  ASC6,7,9&10:–  Ac6veSecurityAdministratortoaccessQualityNetSecurePortal

–  Recommendedtohavetwosecurityadministratorsifpossible–  SignintoQualityNetsecureportalfrequently(every60days)tokeeptheaccountac6ve

KeyPointsToRemember

•  ASC8(influenzavaccina6on):–  NeedtoenrollwithCDCNHSN(5stepprocess),–  Completesetup(3stepprocess)and

-Auser’sSecureAccessManagementServices(SAMS)accountwillbedeac6vatediftheydonotloginatallwithina12monthperiod(1year).Youwillreceiveanemailno6fica6on.

KeyPointsToRemember

•  ASC9and10(colonoscopymeasures):–  Thesamplesizeforeachmeasureisdeterminedbythenumberofcasesthatmeetthedenominatorcriteria.

–  IfyoudonotperformendoscopyproceduresyouSTILLneedtologintowww.qualitynet.orgsecureportalandenterzeroforthenumeratoranddenominatorsinbothmeasures.

KeyPointsToRemember

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•  ASC-12:(facilityseven-dayrisk-standardizedhospitalvisitrateajeroutpa6entcolonoscopy)–  nodatasubmissionorrepor6ngrequiredfromASCs–  forASCsperformingcolonoscopy,confiden6alreportsincludepa6entleveldataandwillbeuploadedtotheQualityNetSecurePortal

•  pa6ent(medicalrecordnumber),dateofbirth,dateofservice

•  typeofhospitalvisit(ED,observa6on,hospital)•  admitngfacility•  diagnosiscodeofhospitalvisitandhospitalID

KeyPointsToRemember

•  ASC13and14(NormothermiaandUnplannedAnteriorVitrectomy)– NormothermiaOutcome-datasubmigedforaSamplingthatmeetthedenominatorcriteria.

– UnplannedAnteriorVitrectomy-datasubmigedforAllPa%entsthatmeetthedenominatorcriteria.

–  IfyoudonotperformtheseproceduresyouSTILLneedtologintowww.qualitynet.orgsecureportalandenterzeroforthenumeratoranddenominatorinbothmeasures.

KeyPointsToRemember

•  EachfacilityshouldhaveatleasttwopeoplesignedupfortheQualityNetemailno6fica6ons– Gotowww.qualitynet.org;clickonambulatorysurgerycenterandclickonemailno6fica6on

KeyPointsToRemember

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2018MedicareHospitalOutpa6entProspec6vePaymentSystem(OPPS)/ASCPayment

FinalRule

•  ReleasedonNovember1,2017•  hgps://s3.amazonaws.com/public-inspec6on.federalregister.gov/2017-23935.pdf

•  ASCQualityRepor6ngProgrambeginsonpage922:Sec6onXIV.RequirementsfortheAmbulatorySurgicalCenterQualityRepor1ng(ASCQR)Program


FinalRule•  MaintainedpreviousmeasuresASC1-4;8-14•  RemovedthreemeasuresfromtheASCQRProgrammeasureset:-ASC–5:Prophylac6cIntravenous(IV)An6bio6cTiming,-  ASC–6:SafeSurgeryChecklistUseand,-  ASC–7:AmbulatorySurgicalCenterFacilityVolumeDataonSelectedAmbulatorySurgicalCenterSurgicalProcedures.

BeginningwiththeCY2019paymentdetermina6on(datacollec6on2017)

•  Delayedimplementa6onof(ASC15a-e):OASCAHPSSurveymeasuresbeginningwiththeCY2020paymentdetermina6on(datacollec6on2018)


FinalRule•  DidnotadoptthenewmeasurefortheCY2021paymentdetermina6on

(datacollec6on2019)andsubsequentyears:-  ASC-16:ToxicAnteriorSegmentSyndrome(TASS)

•  AdoptedtwonewmeasuresfortheCY2022paymentdetermina6onandsubsequentyears:-  ASC-17:HospitalVisitajerOrthopedicAmbulatorySurgery

Procedures-  ASC-18:HospitalVisitajerUrologyAmbulatorySurgeryProcedures

•  ExpansionoftheCMSonlinetooltoallowforbatchsubmissionbeginningwithdatasubmigedduringCY2018fortheCY2020paymentdetermina6onandsubsequentyears

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ASC17:HospitalVisitsajerOrthopedicAmbulatorySurgicalCenterProcedures

•  DataispulledbyCMSfromtheMedicareFeeforServiceadministra1veclaimsbilledbythecenter.

•  Nodatasubmissionorrepor6ngrequiredfromtheASC

•  Datacollec6onperiodfortheCY2022paymentdetermina6onwouldbeCY2019to2020(twocalendaryears).

•  Themeasureoutcomeisall-cause,unplannedhospitalvisits(EmergencyDepartmentVisit,Observa6onStays,UnplannedInpa6entAdmission)withinsevendaysofanorthopedicprocedureperformedatanASC.

•  ClaimsDetailReports(CDR)willbeuploadedtoQualityNetsecureportalfor

facilityreview.

ASC18:HospitalVisitsajerUrologyAmbulatorySurgicalCenterProcedures

•  DataispulledbyCMSfromtheMedicareFeeforServiceadministra1veclaimsbilledbythecenter.

•  Nodatasubmissionorrepor6ngrequiredfromtheASC

•  Datacollec6onperiodfortheCY2022paymentdetermina6onwouldbeCY2019to2020(twocalendaryears).

•  Themeasureoutcomeisall-cause,unplannedhospitalvisits(EmergencyDepartmentVisit,Observa6onStays,UnplannedInpa6entAdmission)withinsevendaysofanurologyprocedureperformedatanASC.

•  ClaimsDetailReports(CDR)willbeuploadedtoQualityNetsecureportalfor

facilityreview.

Ques6ons?

Ø  ForASCQualityRepor6ngProgramQues6ons:ContactHealthServicesAdvisoryGroup(HSAG)(formerlyFMQAI)athgps://cms-ocsq.custhelp.com/orviaphone(866)800-8756MondaythroughFriday,7a.m.to6p.m.EasternTime

Ø  ForCentersforDiseaseControlandPreven6on(CDC)Na6onalHealthcareSafetyNetwork(NHSN)InfluenzaVaccina6onQues6ons:[email protected]“HPSFluSummary-ASC”inthesubjectline

ForassistancewithSAMS,contacttheSAMSHelpDesk@[email protected]

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ContactInforma6on

GinaThroneberry,RN,MBA,CASC,CNORDirectorofEduca6onandClinicalAffairs

AmbulatorySurgeryCenterAssocia6on(ASCA)[email protected]

Join The Community! •  For the resources referenced today and SO

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www.progressivesurgicalsolutions.com/esupport •  Email us at [email protected] •  Or call us! (855) 777-4272

Available on eSupport •  Compliance/Quality Reporting/Overview

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Available on eSupport •  Compliance/Quality Reporting/Data Reporting

Available on eSupport •  Operations/Infection Control/Immunizations

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cms quality measure repor6ng update...asc-14 unplanned anterior vitrectomy december 31, web-based...

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