Input Your Quality Data Correctly

Digital Debut

Input Your Quality Data Correctly

How to ensure successful reporting and avoid penalties

BY KARA NEWBURY AND GINA THRONEBERRY | APRIL 2021

The ASC Quality Reporting (ASCQR) Program data submission deadline is rapidly approaching on May 17, 2021. Not quite ready to report? Please review our last Digital Debut article to walk you through the registration process. Once you are registered, read on for a step-by-step guide on successful reporting. ASCs that fail to report by the deadline are subject to a 2 percent cut to their fee-for-service (FFS) Medicare reimbursements for the following year.

Once you have a Healthcare Quality Information System (HCQIS) Access Roles and Profile (HARP) account and are either a security official or a basic user, you can log into the Hospital Quality Reporting (HQR) platform. Even though ASCs are not hospitals, they are included under the category of hospital quality reporting.

  1. Go to the HQR system home page. You may need to use Google Chrome for this application, as we have heard reported problems with the platform through other browsers.
  2. Enter your User ID or HARP ID (User ID and HARP ID are used interchangeably).
  3. Enter your HARP password.
  4. Select “Login.”

Signing In

  1. Choose the device you will use for the two-factor authentication code. You will receive this code via text or email to the phone number and email address you used when setting up your HARP account.
  2. The check mark will display your choice. Select “Next.”
  3. Enter the code you are sent. Select “Continue.”
  4. You must use the scroll bar to scroll through the terms and conditions. Once you have scrolled through the gray “Accept” box will become blue. If you agree to the terms and conditions, select “Accept.” Next, you will be taken to the HQR Dashboard on the home page (the information on this page will change in the future).
  5. On the drop-down menu under your name, select “My Profile.” Here you can update your password, two-factor authentication and challenge question. This page will list the organizations to which you have access.

Exploring the Home Page

On the home page there are:

  • a “Change Organization” box in the top right corner. You will use this if you report data for more than one ASC; and
  • options that appear if you select the dashboard toggle on the upper left side of the page:
    • Data Submission
    • Program Reporting
    • Administration

Data Submission

  1. Select the “Data Submission” icon to see the two ways to submit your data for the web-based measures.
    1. Select the “File Upload” icon if you are a vendor or want to report data for more than one ASC. The approved CSV file template must be used for this option. Use the “Select Files” or the “Drag Files” option. Most ASCs do not use this feature.
    2. Select the “Data Form” icon and then “Launch Data Form” to direct you to the ASC web-based submission form to enter data.
  2. Review the “Payment Year” in the upper right corner to make certain it is the correct year. This is the payment year not submission year. The data being submitted in 2021 is for payment year 2022.
  3. To enter your data, select the green “Start Measure” icon to open the data entry page.

Data Entry by Measure

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

If an ASC does not perform procedures related to this measure, select the box under the measure name and description that states, “Please enter zeros for this measure as I have no data to submit.”

You will be prompted by a pop-up box, which is a safety mechanism, to confirm you want to keep the zeros. Select the blue “Confirmed” box and the system will autofill zeros in this measure for you.

The next page will show a green check mark and “Complete” by ASC-9 if the entry was successful. This will be the case once data is successfully submitted for any measure.

If an ASC does perform colonoscopies, select the green “Start Measure” icon next to ASC-9. Remember:

  • Any area with red asterisks indicates a mandatory field.
  • For ASC-9, the numerator and denominator must be completed.
  • The “total population” and “sample size” are not mandatory.
  • The “sample frequency” is auto selected for N/A but can be changed.
  • Enter the data and select the green “Save and Return” icon.

ASC-11 Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery

This measure is voluntary. If you are not collecting data on this measure, you can leave this section blank or submit zeroes in the system and not be penalized.

If an ASC does perform procedures related to this measure and chooses to report, select the green “Start Measure” icon next to ASC-11. Keep in mind:

  • Any area with red asterisks indicates a mandatory field.
  • For ASC-11, the numerator and denominator must be completed.
  • The “total population” and “sample size” are not mandatory.
  • The “sample frequency” is auto selected for N/A but can be changed.
  • Enter the data and select the green “Save and Return” icon.

ASC-13 Normothermia

If an ASC does not perform procedures related to this measure, select the box under the measure name and description that states, “Please enter zeros for this measure as I have no data to submit.”

You will be prompted by a pop-up box, which is a safety mechanism, to confirm you want to keep the zeros. Select the blue “Confirmed” box and the system will autofill zeros in this measure for you.

The next page will show a green check mark and the word “Complete” by ASC-13 once you have successfully entered your data.

If an ASC does perform procedures related to this measure, select the green “Start Measure” icon next to ASC-13. Note:

  • Any area with red asterisks indicates a mandatory field.
  • For ASC-13, the numerator and denominator must be completed.
  • The “total population” and “sample size” are not mandatory.
  • The “sample frequency” is auto selected for N/A but can be changed.
  • Enter the data and select the green “Save and Return” icon.

ASC-14 Unplanned Anterior Vitrectomy

If an ASC does not perform procedures related to this measure, select the box under the measure name and description that states, “Please enter zeros for this measure as I have no data to submit.”

You will be prompted by a pop-up box, which is a safety mechanism, to confirm you want to keep the zeros. Select the blue “Confirmed” box and the system will autofill zeros in this measure for you.

The next page will show a green check mark and the word “Complete” by ASC-14 once you have successfully entered your data.

If an ASC does perform procedures related to this measure, select the green “Start Measure” icon next to ASC-14. Remember:

  • Any area with red asterisks indicates a mandatory field.
  • For ASC-14, the numerator and denominator must be completed.
  • Enter the data and select the green “Save and Return” icon.

Partial Submission

If you have a partial submission, you will not be able to select the “I’m ready to submit” icon. For example, if you have entered data for ASC-9 and do not have data yet for ASC-13 and ASC-14, the “I’m ready to submit” icon will remain gray.

Any data you have entered will stay in the data collection tool, so you do not have to re-enter that data. However, the data will not cross over into the warehouse and show as submitted until the “I’m ready to submit” icon turns blue.

You will need to enter the data for ASC-9, ASC-13 and ASC-14 for the “I’m ready to submit” icon to turn blue.

Complete Data Submission

Once you have entered all the data, the “I’m ready to submit” icon will turn blue.

Select the blue “I’m ready to submit” icon. Data is not submitted until you select the blue “I’m ready to submit” icon.

A green check mark and the word “Complete” will appear next to all measures. You will be able to review the numbers you entered. If a mistake was made, you can click the blue “Edit Measure” icon next to each measure and the data entry page will open to revise the data. If any data is edited, you will need to select the blue “I’m ready to submit” icon again.

Look at the banner at the top to make certain there is a green check mark next to “Submit.”

You can print a screenshot or use the “Export Data” feature to keep a copy for your records.

Congratulations! You are done with ASCQR Program reporting until next year.

If you need assistance, please call the QualityNet Help Desk at 866.288.8912 or contact ASCQR Program Support through the Quality Question and Answer Tool.