ASCs Resume Data Collection for ASC-1 through ASC-4

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ASCs Resume Data Collection for ASC-1 through ASC-4

Surgery centers must report on all patients, not just FFS Medicare beneficiaries

At the beginning of this month, the Centers for Medicare & Medicaid Services (CMS) resumed data collection for four outcomes measures in the ASC Quality Reporting (ASCQR) Program. Surgery centers should have started collecting data on January 1 for 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 for all patients, not just fee-for-service (FFS) Medicare beneficiaries.

ASC-1 through ASC-4

In 2022 rulemaking, CMS decided to resume data collection and reporting for ASC-1 through ASC-4, outcomes measures that the agency previously suspended as of January 1, 2019. Facilities do not report these measures on claims as was previously required. Instead, ASCs must collect data for these measures for all patients and will submit it in calendar year (CY) 2024 via the Hospital Quality Reporting (HQR) secure portal (also known as QualityNet). Data collection will be due on May 15, 2024.

Background on ASC-1 through ASC-4

In the 2019 ASC proposed payment rule, CMS indicated that ASC-1 through ASC-4 had “topped out,” meaning the outcomes being reported by facilities were high. While CMS had proposed to simply remove the measures from the ASCQR Program, in the 2019 final payment rule, the agency chose instead to suspend the measures, indicating it might reinstate them in the future. CMS noted that since ASCs were collecting these adverse events only as quality data codes (QDC) on FFS Medicare claims, they were not reporting adverse events that were occurring outside of the FFS Medicare population. As the agency develops “future revisions for the data collected for these measures,” CMS stated it will “take into consideration other data submission methods that may allow for the reporting of adverse events across payers and will consider commenters’ feedback toward the future updates to the measures.”

Previously, when submitting on claims, ASCs that identified an erroneous or missing QDC code were unable to correct or add a QDC code if the claim had already been submitted to Medicare. In the 2019 final rule, CMS stated that “revising the data submission method for the measures, such as via QualityNet, would address this issue and allow facilities to correct any data submissions errors, resulting in more complete and accurate data.” ASCA supported the return of these outcomes measures, and advocated for CMS to add similar outcomes measures to the Hospital Outpatient Quality Reporting (OQR) Program.

In 2022 rulemaking, CMS decided it was time to bring back ASC-1 through ASC-4, noting in the CY 2022 final rule that “data collection will resume beginning CY 2023 with reporting in CY 2024 and payment in CY 2025.” CMS stated “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 other data points that facilities are collecting on their own, ASCs can choose to collect data 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).

While CMS has not yet added similar measures to the Hospital OQR Program, ASCA will continue to advocate for better alignment of the programs, which will allow for the public to better compare the sites of service.

ASCQR Program Overview

Other than resumed data collection for ASC-1 through ASC-4, CMS has not added any new measures on which ASCs will report 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.