cms quality reporting for ascs
DESCRIPTION
CMS Quality Reporting for ASCs. Gina Throneberry, RN, MBA, CASC, CNOR Director of Education and Clinical Affairs Ambulatory Surgery Center Association (ASCA). Learning Objectives. Participants will: - PowerPoint PPT PresentationTRANSCRIPT
CMS Quality Reporting for ASCs
Gina Throneberry, RN, MBA, CASC, CNORDirector of Education and Clinical Affairs
Ambulatory Surgery Center Association (ASCA)
Learning Objectives
• Participants will:• Identify quality reporting by Centers for Medicare
& Medicaid Services (CMS) for Ambulatory Surgery Centers (ASCs)
• Understand the history of quality measure development
• Collect and report the data for the required quality measures
General FAQs about the CMS ASC Quality Reporting Program
• I would like clarification on the definition of an Ambulatory Surgical Center (ASC) as it relates to the requirements for the ASC Quality Reporting Program. My understanding is that only free-standing ASCs that are billing with their own CCN would be required to submit under that program. Is this correct?
You are correct. ASCs have their own ASC numbers - an alphanumeric code where the third digit is the letter "C" - and bill using their own system. An ASC that is part of a hospital's regional outpatient facility that is billing under the hospital's CCN would not be included. The ambulatory surgery cases billed under the hospital's CCN would be eligible for inclusion in the relevant measures in the Hospital Outpatient Quality Reporting (OQR) Program. *
*Per www.qualitynet.org
General FAQs about the CMS ASC Quality Reporting Program
• What is a CCN, and where can I locate it?A Center for Medicare and Medicaid Services (CMS) Certification Number, or CCN, is established by CMS for each facility and designates the facility as a CMS-certified, free standing ASC. Your billing department should serve as a good resource for locating this number. An ASC CCN is an alphanumeric 10 digit number - the first two digits represent the state's number, and the following letter is a "C." For example, an ASC in Florida would have a CCN that looks like "10C000xxxx.“ *
*Per www.qualitynet.org
ASCQR Program Rule HistoryRule Reference
Proposed or Final
RuleFederal Register (FR) Referencehttps://www.federalregister.gov Program Highlights
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
Final 74 FR 60656 Discussed/Not implemented
CY 2009OPPS/ASC
Final 73 FR 68780 Discussed/Not implemented
CY 2008OPPS/ASC
Final 72 FR 66875 Discussed/Not implemented
2012 HOPD/ASC Final Rule (CMS 1525FC) Quality Reporting Program
On November 1, 2011, Medicare released the calendar year (CY) 2012 Medicare Hospital Outpatient Prospective Payment System (OPPS)/ ASC Payment final rule (1552 pages)
The ASC Quality Reporting Program was implemented beginning with the CY 2014 payment determination, data collection began in CY 2012 for some of the measures
Pay for Reporting; Not Pay for Performance at this time
ASCs that fail to successfully report will face a 2% facility fee reduction in future year’s rates.
ASCQR Program Measures SummaryNumber Measure Title Type of Measure Initial Encounter/
Reporting Date Initial Payment Determination
Year
Patients
ASC-1 Patient Burn Claims-Based October 1, 2012 CY 2014 Medicare ASC-2 Patient Fall Claims-Based October 1, 2012 CY 2014 Medicare ASC-3 Wrong Site, Wrong Side, Wrong
Patient, Wrong Procedure,Wrong Implant
Claims-Based October 1, 2012 CY 2014 Medicare
ASC-4 Hospital Transfer/Admission Claims-Based October 1, 2012 CY 2014 Medicare ASC-5 Prophylactic Intravenous (IV)
Antibiotic Timing Claims-Based October 1, 2012 CY 2014 Medicare
ASC-6 Safe Surgery Checklist Use Web-Based CY 2012 July – August 2013
CY 2015 All
ASC-7 ASC Facility Volume Data on Selected ASC Surgical Procedures
Web-Based CY 2012 July – August 2013
CY 2015 All
ASC-8 Influenza Vaccination Coverage among Healthcare Personnel
Web-Based via NHSN
Entry TBD; October 2014 – March
2015
CY 2016 Health Care Personnel
ASC-9 Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
Web-Based CY 2014 January 1 – August 15,
2015
CY 2016 Sampling
ASC-10 Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use
Web-Based CY 2014 January 1 – August 15,
2015
CY 2016 Sampling
ASC-11 Cataracts – Improvement in Patient’s Visual Function within 90 days Following Cataract Surgery
Web-Based CY 2014 January 1 – August 15,
2015
CY 2016 Sampling
ASC Quality Collaboration, Inc.Measures Implementation Guide
www.ascquality.org
CMS Ambulatory Surgical Center Quality Reporting Program
• CMS ASC Quality Reporting Program Quality Measures Specifications Manual• To date- 6 versions (April 2012-December 2013)• Latest version- 3.0a (December 2013)
• Located @ www.qualitynet.org under ASC tab• Included in this manual:
• Measure specifications• Data collection and submission• Quality Data Codes (QDCs)
Measures for ASCs
ASC Program Measurement Set for the CY 2014 and 2015 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*
*Data submission began in CY 2012
How Will the Data be Reported?• 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 Quality Net (www.qualitynet.org) • Safe Surgery Check List Use• ASC Volume of Selected Procedures for all-patients
• Web Based Reporting Via Center for Disease Control’s (CDC) National Health Care Safety Network (NHSN) (www.cdc.gov/nhsn/index.html) • Influenza Vaccination Coverage Among Health Care Personnel
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
General FAQs about the CMS ASC Quality Reporting Program
• Do we need to include Pre-Admission Testing (PAT) visits conducted in an ASC for the ASCQR Program? A visit for PAT is not considered an ASC admission for purposes of the ASCQR Program.*
• Can we submit claims to correct G codes? Do not re-submit a claim only for the purpose of correcting or adding G-codes. Resubmission of claims should occur only to collect the payment from the original date of service. *
*Per www.qualitynet.org
General FAQs about the CMS ASC Quality Reporting Program
• If a patient is admitted to the ASC, but the case is cancelled before any procedure is performed, does quality measure data need to be reported for this case? If the ASC submits a claim for Medicare reimbursement for this case, then the appropriate QDCs should be reported as this claim will be included in the completeness of reporting calculation.*
*Per www.qualitynet.org
Inpatient/Long Term Care Hospital Prospective Payment System (IPPS) Final Rule
• 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:• Data completeness and validation• Reconsideration and appeals process• Limited details for public reporting of data
Additional Quality Reporting Info from the IPPS* Final Rule (July 2012)
• ASC information begins on page 1534; Section E. Proposed Quality Reporting Requirements for Ambulatory Surgical Centers (ASCs)
• Participation in the CMS ASC Quality Reporting Program. Page 1540
• Publicly reporting quality data. Page 1541.
*Inpatient Prospective Payment Systems
Additional Quality Reporting Info from the IPPS* Final Rule (July 2012)
• The completeness threshold is set at 50%. Page 1548 • ASCs will be considered successful reporters and get their full
payment if 50% of the relevant claims contain the quality data codes (2012 and 2013).
• There is a process for an extension in extraordinary circumstances. Page 1554.
• The reconsideration and appeals process is based on the one the hospital uses now. Page 1558.
*Inpatient Prospective Payment Systems
Participation and Non Participation• Once an ASC submits any quality measure data, the center
would be considered participating• To receive the full annual payment update (APU), an ASC
must meet all program requirements:• submits quality measure data (i.e., Quality Data Codes [QDCs]) on
the CMS Form 1500 • submits web-based measure data
• 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.
• For ASCs participating in the program, quality measure data submitted could be made publicly available.
Participation and Non Participation• 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.
Extraordinary Circumstances Extension/ Waiver Process
• 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
Reconsideration 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
Measures for ASCsASC Program Measurement Set for the CY 2015 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}
*New measures for CY 2015 payment determination; Data collection began CY 2012
Measure Details
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:• prior to administering anesthesia, • prior to incision, and • prior to the patient leaving the operating room
• Applies to all ASCs
Measure Details
Safe Surgery Checklist Use• 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
Safe Surgery Checklist Resources• World Health Organization (WHO)
• http://www.who.int/patientsafety/safesurgery/ss_checklist/en/
• SafeSurg.org:• For a modifiable template: http://www.safesurg.org/template-
checklist.html• For examples, including for endoscopy centers:
http://www.safesurg.org/modified-checklists.html
• AORN (combines WHO checklist and JC universal protocol)• http://www.aorn.org/PracticeResources/ToolKits/
CorrectSiteSurgeryToolKit/Comprehensivechecklist/
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
• The specifications manual version 3.0a released in December 2013 contains a new table of HCPCS or CPT codes.
• This revision was based on claims data from 2012, the top 100 procedures (based on volume) were determined, and the corresponding codes were used to update the table within the measure.
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 CodesGenitourinary 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 CodesNervous 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
How Will the Data be Reported?• 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 Quality Net (www.qualitynet.org) • Safe Surgery Check List Use• ASC Volume of Selected Procedures for all-patients
• Web Based Reporting Via Center for Disease Control’s (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?
• Web Based Reporting via Quality Net (www.qualitynet.org) • Safe Surgery Check List Use• ASC Volume of Selected Procedures for all-patients
• 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
Requirements for QualityNet Account and Administrator
• A QualityNet account is required to submit quality data to the QualityNet Web site
• ASCs will need to identify and register a QualityNet administrator who follows the registration process located on the QualityNet Web site
• Allow 6 weeks for the security administrator process to be completed
• QualityNet accounts are automatically deactivated after a 120-day period of inactivity in accordance with CMS security policy.
QualityNet Home Pagewww.qualitynet.org
QualityNet Home Page
ASC Registration is located in a blue box on the left hand side of the home page
QualityNet ASC Registration
Additional Requirements for QualityNet Account and Administrator
• As of May 31, 2013, the Centers for Medicare & Medicaid Services (CMS) is now requiring QualityNet users for the ASC Quality Reporting Program complete an additional user enrollment process to ensure access to the Secure QualityNet Portal.
• After receiving a user ID and password, the security administrator will now be required to download the Symantec VIP Access application (Symantec VIP multifactor credential application).
• When logging in to the portal for the first time, security administrators will be guided through a six step New User ‐Enrollment Process that includes personal identity verification conducted by Experian, an external service enlisted by CMS.
Secure QualityNet Portal Log In
QualityNet Portal Log-in
QualityNet Portal Registration
Start/Complete New User Enrollment
Quick Link to VIP Access App
QualityNet Secure Portal
Measures for ASCsASC 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
Measure DetailsInfluenza Vaccination Coverage among Healthcare Personnel (HCP)• Intent: assess the percentage of HCP immunized for influenza
during the flu season• Center for Disease Control (CDC) in the process of revising
measure specifications for ASCs• 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
Influenza Vaccination Coverage Among Healthcare Personnel (HCP)• Measurement 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
• Deadline for ASC submission will be finalized with the final rule for CY 2015
Enrollment Steps
• 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
SAMS
• Users must fax or mail notarized proof of identity to CDC.• This is not a background check – this information
will only be used to verify your identity and will not be shared outside of NHSN
• 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 to NHSN
• Report to CDC’s National Healthcare Safety Network (NHSN): www.cdc.gov/nhsn/index.html October 1, 2014 through March 31, 2015
• Enter data for all numerator and denominator categories
Influenza Vaccination Summary 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
Denominator Categories
48
• Employee HCP • Non-Employee HCP: Licensed independent
practitioners (physicians, advance practice nurses, and physician assistants)
• Non-Employee HCP: Adult students/trainees and volunteers
Numerator Categories
• Influenza vaccinations– Received at this
healthcare facility– Received elsewhere
• Medical contraindications
• Declinations • Unknown status
Notes on Reporting – Example 10 + 20 + 15 + 5 + 5 = 55 70 + 10 + 10 + 5 + 5 = 100 20 + 2 + 1 + 1 + 1 = 25
How Will the Data be Reported?• 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 Quality Net (www.qualitynet.org) • Safe Surgery Check List Use• ASC Volume of Selected Procedures for all-patients
• Web Based Reporting Via Center for Disease Control’s (CDC) National Health Care Safety Network (NHSN) (www.cdc.gov/nhsn/index.html) • Influenza Vaccination Coverage Among Health Care Personnel
2013 Medicare Hospital Outpatient Prospective Payment System (OPPS)/ASC
Payment Final Rule
• Released on November 1, 2012• http://www.gpo.gov/fdsys/pkg/FR-2012-11-15
/pdf/2012-26902.pdf (page 979-1010/1249)
• No new measures proposed
2014 Medicare Hospital Outpatient Prospective Payment System (OPPS)/ASC Payment Final Rule
• Released on November 27, 2013• www.gpo.gov/fdsys/pkg/FR-2013-12-10/pdf/2013-28737.pd
f• 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)
New ASC Measures for CY 2016 and Subsequent Payment Determination Years
• 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)
Endoscopy/Polyp Surveillance: Normal Colonoscopy
• 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
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: V13.89, V18.51, V12.72, V16.0, V10.05
(In October 2014 the ICD-9 codes will be updated to ICD-10)
Endoscopy/Polyp Surveillance: Adenomatous Polyp
• 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.
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)
Endoscopy/Polyp Surveillance: Adenomatous Polyp
• Inclusions:Patients aged ≥ 18 years on date of encounter AndDiagnosis for history of colonic polyp(s) (ICD-9-CM): V12.72, V13.89, 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
(In October 2014 the ICD-9 codes will be updated to ICD-10)
Cataract: Improvement in Patients Visual Function within 90 days
• 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
Cataract: Improvement in Patients Visual Function within 90 days
• Exclusions: Patients who did not complete both a pre-operative and post-operative survey
• Inclusions: Patients aged ≥18 years AndCPT (with or without modifiers): 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984
Cataract: Improvement in Patients Visual Function within 90 days
Definition for Survey:• The data collection instrument is specified as an
assessment tool that has been appropriately validated for the population for which it is being used.
• The same data collection instrument used pre-operatively should be used post-operatively.
• The surveys can be completed by phone, mail, or email during physician follow-up.
Cataract: Improvement in Patients Visual Function within 90 days
Examples of tools for visual function assessment include, but are not limited to: • National Eye Institute-Visual Function Questionnaire – VFQ-25www.rand.org/health/surveys_tools/vfq.html• Visual Function (VF)-14www.med.teikyo-u.ac.jp/~ortho/med/reh/VF-14.html• Modified VF-8http://ascrs.org/sites/default/files/resources/2013%20Cataracts%20Measures%20Group%20Post-Surgery%20VF-8R_0.pdf• Activities of Daily Vision Scale (ADVS)• Catquest• Modified Catquest-9http://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/OPX/A/OPX_90_8_2013_04_04_LUNDSTROM_201940_SDC1.pdf
Data Collection Tool for Cataract and Endoscopy Measures
• http://www.oqrsupport.com/asc/tools
Sampling Size SpecificationsASC-9, ASC-10, or ASC-11
Population Per Year 0-900Yearly Sample Size 63Quarterly Sample Size 16Monthly Sample Size 6Population Per Year ≥901Yearly Sample Size 96Quarterly Sample Size 24Monthly Sample Size 8
How Will the Data be Reported?• 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 Quality Net (www.qualitynet.org)• Safe Surgery Check List Use• ASC Volume of Selected Procedures for all-patients
• Web Based Reporting Via Center for Disease Control’s (CDC) National Health Care Safety Network (NHSN) (www.cdc.gov/nhsn/index.html)
• Influenza Vaccination Coverage Among Health Care Personnel
• Web Based Reporting via Quality Net (www.qualitynet.org)• Endoscopy/Polyp Surveillance (normal)• Endoscopy/Polyp Surveillance (adenomatous)• Cataract: improvement in visual function
ASCQR Program Measures SummaryNumber Measure Title Type of Measure Initial Encounter/
Reporting Date Initial Payment Determination
Year
Patients
ASC-1 Patient Burn Claims-Based October 1, 2012 CY 2014 Medicare ASC-2 Patient Fall Claims-Based October 1, 2012 CY 2014 Medicare ASC-3 Wrong Site, Wrong Side, Wrong
Patient, Wrong Procedure,Wrong Implant
Claims-Based October 1, 2012 CY 2014 Medicare
ASC-4 Hospital Transfer/Admission Claims-Based October 1, 2012 CY 2014 Medicare ASC-5 Prophylactic Intravenous (IV)
Antibiotic Timing Claims-Based October 1, 2012 CY 2014 Medicare
ASC-6 Safe Surgery Checklist Use Web-Based CY 2012 July – August 2013
CY 2015 All
ASC-7 ASC Facility Volume Data on Selected ASC Surgical Procedures
Web-Based CY 2012 July – August 2013
CY 2015 All
ASC-8 Influenza Vaccination Coverage among Healthcare Personnel
Web-Based via NHSN
Entry TBD; October 2014 – March
2015
CY 2016 Health Care Personnel
ASC-9 Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
Web-Based CY 2014 January 1 – August 15,
2015
CY 2016 Sampling
ASC-10 Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use
Web-Based CY 2014 January 1 – August 15,
2015
CY 2016 Sampling
ASC-11 Cataracts – Improvement in Patient’s Visual Function within 90 days Following Cataract Surgery
Web-Based CY 2014 January 1 – August 15,
2015
CY 2016 Sampling
General FAQs about the CMS ASC Quality Reporting Program
• When will ASC Quality Reporting end?The Ambulatory Surgical Center Quality Reporting Program is an ongoing program that will continue to evolve and grow, with new measures being added periodically.*
*Per www.qualitynet.org
Measures for Future Consideration
• Clinical quality of care• Patient safety• Care coordination• Patient experience of care: ASC Consumer
Assessment of Healthcare Providers and Systems (CAHPS) patient experience survey
• Surgical outcomes• Surgical complications• Complications of anesthesia• Patient-reported outcomes of care
Websites with Additional Information
• 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)http://qualitynet.org
• FMQAI website (CMS national support contractor)http://oqrsupport.org
Additional QuestionsContact 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
References 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 ASC Quality Collaboration Implementation Guide, Version 1.6, October 26, 2011. Available at
http://ascquality.org/documents/ASCQualityCollaborationImplementationGuide.1.6.pdf. Last accessed July 15, 2013.
CMS ASC Quality Reporting Program Quality Measures Specifications Manual, Version 3.0a, December 2013. Available at www.qualitynet.org
Quality Net at www.qualitynet.org
Questions/Comments
Gina Throneberry, RN, MBA, CASC, CNORAmbulatory Surgery Center Association (ASCA)
Director or Education and Clinical Affairs [email protected]