ASC Quality Reporting Program Requirements for 2019

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ASC Quality Reporting Program Requirements for 2019

A look ahead

With the ASC Quality Reporting (ASCQR) Program web-based measure deadline of May 15, 2018, in the rearview mirror, it is time to look ahead to the data that will be reported for the Centers for Medicare & Medicaid Services (CMS) ASCQR Program in 2019 for 2020 payment determinations. It also is a good time to review some of the publicly available data on current measures to determine where ASCs can improve.

There are 10 measures eligible Medicare- certified facilities must report to avoid Medicare payment reductions in 2020. As a reminder, ASCs that have fewer than 240 Medicare claims—primary plus secondary payer—per year during a reporting period for a payment determination year are not required to participate in the ASCQR Program for the subsequent reporting period for that subsequent payment determination year. This includes all program requirements, both claims-based measures and measures entered via a web-based tool.

Here is a breakdown, by measure, of what is required.

Claims-Based Measures

ASCs must continue to report on measures ASC-1: Patient Burn, ASC-2: Patient Fall, ASC-3: Wrong Site/Side/ Patient/Procedure/Implant and ASC- 4: Hospital Admission/Transfer. These claims-based measures are entered as G-codes on the CMS-1500 claim form. Results are reported as a rate per 1,000 cases. Nationwide, performance on these measures is extremely high, and ASCs even saw improvement for all four measures between 2015 and 2016.

Measure 2015 2016
ASC-1 0.181 0.152
ASC-2 0.095 0.078
ASC-3 0.022 0.020
ASC-4 0.410 0.359

CMS may eventually determine ASCs have “topped out” on these measures, meaning there is little room for improvement. This is why ASC-5: Prophylactic Intravenous (IV) Antibiotic Timing and ASC-6: Safe Surgery Checklist Use were removed from the ASCQR Program.

Web-Based Measures

ASC-8: Influenza Vaccination Coverage among Healthcare Personnel data collection will take place for the influenza season between October 1, 2018, and March 31, 2019, with a reporting deadline of May 15, 2019. To report ASC-8 through the National Healthcare Safety Network (NHSN) as required, someone from your ASC must be registered with NHSN.

Failure to report on this measure continues to be the number one reason facilities do not receive their full payment update. Compliance has improved slightly, up from 74.62 percent in 2014– 2015 to 77.54 percent in 2016–2017. From a CMS perspective, there is still room for improvement. On a recent webinar, CMS contractors indicated that the main issues impacting successful reporting are: facility not enrolled in time; staff turnover; incorrect or missing CMS Certification Number (CCN); and a failure to add a reporting plan for the current flu season.

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 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.

The percentage of patients receiving appropriate recommendation for followup screening colonoscopy, as captured with ASC-9, declined from 80.98 percent in 2015 to 77.78 percent in 2016. On the webinar discussing reporting issues, CMS contractors indicated that facilities had problems with: appropriate documentation of a medical reason for exclusion; exclusion regarding the age of the patient; and lack of documentation regarding the follow-up interval.

The Specifications Manual was updated to provide clarity on some of these points; that documentation of medical reason(s) for not recommending at least a 10-year follow-up interval could include cases of inadequate prep, familial or personal history of colonic polyps, patients with no adenoma and age greater than 66 years old or life expectancy of less than 10 years. Medical reason(s) are at the discretion of the physician. Documentation indicating no follow-up colonoscopy is needed or recommended is only acceptable if the patient’s age is documented as at least 66 years old or life expectancy is less than 10 years.

The percentage of patients with history of polyps receiving follow-up colonoscopy in the appropriate timeframe, data publicly reported as ASC-10, also went in the wrong direction, from 79.90 percent in 2015 to 73.21 percent in 2016. The primary issues with reporting have been: confusion about documentation of the last colonoscopy—which is particularly difficult if the patient did not have the prior colonoscopy performed in that facility—and proper documentation of medical reasons.

ASC-12: Facility Seven-Day Risk- Standardized Hospital Visit Rate after Outpatient Colonoscopy data also is made public as a mandatory measure in the ASCQR Program, but there is no reporting requirement on the facility as the data will be pulled from claims previously submitted by the hospital that the patient visits within seven days of the colonoscopy.

As with all measures in the ASCQR Program, ASCs are given access to preview their ASC-12 data before it is made public. Since ASC-12 is a measure that captures all-cause, unplanned hospital visits, there certainly could be some patients counted who have nothing to do with the services your facility provides. It is recommended that facilities review their reports to determine how many of the hospital visits could be tied to the performance of the colonoscopy within their facilities.

In addition to the measures above which ASCs are currently reporting, there are two new measures on which ASCs are collecting data in 2018 for reporting beginning in 2019.

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 the post-anesthesia care unit (PACU). CMS has added some tools to help ASCs with this measure.

Each ASC should identify surgical patients with general or neuraxial— epidural or spinal—anesthesia equal to or greater than 60 minutes in duration. That number will be the denominator. Cases with strictly sedation or local anesthesia should not be included. Next, the ASC should determine the start time of anesthesia. If there is no start time, that patient should not be included in the denominator. Likewise, if there is no end time, that patient should not be included in the denominator either.

Next, the facility should determine the numerator by calculating how many patients in the denominator population had the required body temperature— greater than or equal to 96.8 degrees Fahrenheit—within 15 minutes of arriving in the PACU.

The data that is reported to CMS will be based on a sampling of eligible cases, “the denominator.” If the population of eligible cases is 63–900, a sample of 63 may be used. If the population of eligible cases is greater than or equal to 901, a sample of at least 96 should be used. If the population is fewer than 63 cases, the total population of cases is required.

ASC-14: Unplanned Anterior Vitrectomy is used to assess the percentage of cataract surgery patients who have an unplanned anterior vitrectomy. It is a straight-forward measure: the numerator is the total number of patients who had an unplanned anterior vitrectomy, and the denominator is all cataract surgery patients. There are no exclusions for this measure.

Visit ASCA’s 2018 Quality Reporting Requirements web page for more information, including the current Ambulatory Surgical Center Quality Reporting Specifications Manual.