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 2019, there are five measures required for eligible Medicare-certified facilities* to avoid Medicare payment reductions in 2020.

*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 and ASC-10: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use are web-based measures that are also 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, for both ASC-9 and ASC-10 you will enter “0” in the numerator and the denominator. Note: ASC-10 was removed from the ASC Quality Reporting Program for 2021 payment determinations and beyond, but facilities must enter data collected in 2019 in order to avoid penalty in 2020.

  • 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. Data collection for this measure began in 2018 and the first year of required reporting is 2019. Like ASC-9 and ASC-10, this is a sampling measure.

  • ASC-14: Unplanned Anterior Vitrectomy is used to assess the percentage of cataract surgery patients who have an unplanned anterior vitrectomy. Data collection for this measure began in 2018 and the first year of required reporting is 2019.

Visit ASCA's 2019 Quality Reporting Requirements web page and the Ambulatory Surgical Center Quality Reporting Specifications Manual for more information on all measures.

Additional Resources


ASC Quality Reporting Measures Specifications Manual

ASCQR Program Resources

ASCQR Program Reference Checklist

OAS CAHPS Survey® FAQs

QualityNet

Safe Surgery Checklist Information



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