ASC Quality Reporting Program Requirements Change in 2023

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ASC Quality Reporting Program Requirements Change in 2023

Data collection resumes for ASC-1 through ASC-4

On January 1, 2023, ASCs will need to resume collecting data for four outcomes measures in the ASC Quality Reporting (ASCQR) Program: ASC-1: Patient Burn; ASC-2: Patient Fall; ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant; and ASC-4: All-Cause Hospital Transfer/Admission.

ASC-1 through ASC-4

The Centers for Medicare & Medicaid Services (CMS) decided in 2022 rulemaking to resume data collection and reporting for ASC-1 through ASC-4, which were previously suspended as of January 1, 2019. Facilities will not report these measures on claims as was previously required. Instead, ASCs will collect data for these measures for all patients, not just fee-for-service (FFS) Medicare beneficiaries, and will submit the data in calendar year (CY) 2024 via the Hospital Quality Reporting (HQR) secure portal. Surgery centers will need to report this data through the HQR secure portal by May 15, 2024.

In 2022 rulemaking, CMS indicated that “reporting via HQR allows ASCs to make corrections during the data submission period which was not possible in the past if an ASC identified an erroneous or missing QDC on a claim that had already been submitted and processed, reduces the amount of time and resources required to submit measure data, and simplifies the requirements of the ASCQR Program by streamlining the number of methods required for quality measure data submission.”

As with many other data points that facilities are collecting on their own, ASCs can choose to collect through Excel spreadsheets, their electronic health records or paper records. When reported via the HQR portal in 2024, facilities will enter annual figures (for instance, for ASC-1, the total number of patient burns that occurred in the facility during the data collection year).

ASCQR Program Overview

Besides the resumed data collection for ASC-1 through ASC-4, there are no other significant changes to the ASCQR Program in 2023. The entire measure set for CY 2023 data collection/CY 2025 payment determination includes:

ASCQR Program Measure Set for the CY 2023 Data Collection/CY 2025 Payment Determination
ASC # Measure Name
ASC-1 Patient Burn
ASC-2 Patient Fall
ASC-3 Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant
ASC-4 All-Cause Hospital Transfer/Admission
ASC-9 Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
ASC-11 Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery*
ASC-12 Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy
ASC-13 Normothermia Outcome
ASC-14 Unplanned Anterior Vitrectomy
ASC-17 Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures
ASC-18 Hospital Visits after Urology Ambulatory Surgical Center Procedures
ASC-19 Facility-Level 7-Day Hospital Visits after General Surgery Procedures Performed at Ambulatory Surgical Centers
ASC-20 COVID-19 Vaccination Coverage Among Health Care Personnel
*The ASC-11 measure is voluntarily collected, as set forth in the CY 2015 OPPS/ASC final rule (79 FR 66984 through 66985).

As a reminder, reporting on ASC-11: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery is voluntary, and ASCA will continue to advocate for it to remain voluntary.

ASC-20 remains in the ASCQR Program, despite objections from ASCA as to the administrative burden and absence of evidence as to the measure’s value for patients and facilities. This is the only measure for which ASCs have to submit data via the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN), and the only measure for which data must be submitted quarterly. The upcoming ASC-20 deadlines are:

Quarterly Data Submission Deadline
Quarter 3 2022 (July 1 – September 30, 2022) February 15, 2023
Quarter 4 2022 (October 1 – December 31, 2022) May 15, 2023
Quarter 1 2023 (January 1 – March 31, 2023) August 15, 2023
Quarter 2 2023 (April 1 – June 30, 2023) November 15, 2023

Write Kara Newbury with questions.