ASC - Texas Ambulatory Surgery Center Society

Report
Gina Throneberry, RN, MBA, CASC, CNOR
Director of Education and Clinical Affairs
Ambulatory Surgery Center Association (ASCA)

Participants will:
• Identify quality reporting by Centers for Medicare
& Medicaid Services (CMS) for Ambulatory Surgery
Centers (ASCs)
• Understand the history of quality measure
development
• Learn to collect and report the data for the
required quality measures

Centers for Medicare & Medicaid Services (CMS) / State

Life Safety Code (LSC)

Occupational Safety and Health Administration (OSHA)

Food and Drug Administration (FDA)

Environmental Protection Agency (EPA)

Drug Enforcement Agency (DEA)

Federal Aviation Administration (FAA)
American Recovery and Reinvestment Act of 2009
 Stimulus money provided the down payment for a nationwide
effort to reduce health care associated infections in standalone or same-day surgical centers.

Interpretive Guidelines for the Conditions for Coverage
provide guidance on the meaning of the rules and further
advice on how ASCs should comply.

State Operations Manual
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/som107ap_l_ambulatory.pdf

Infection Control Surveyor Worksheet
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107_exhibit_351.pdf

Medicare requires ASCs to comply with the 2000
edition of the Life Safety Code, updated and
published by the National Fire Protection
Association.

In April 2014, CMS announced the proposal to adopt
the National Fire Protection Association’s (NFPA)
2012 editions of the Life Safety Code (LSC) and the
Health Care Facilities Code (HCFC).
◦ The requirement is currently a 1-hour minimum separation between
ASCs and other adjacent tenants/occupancies. This proposal would
require a 2-hour separation in un-sprinkled buildings.
◦ More extensive alarms, and more elaborate medical air compressors
and clinical vacuum on piped medical gas systems would be required
which would cause needed upgrades to systems.
◦ For windowless anesthetizing locations: “The ASC must have a supply
and exhaust system that (i) Automatically vents smoke and products of
combustion, (ii) Prevents recirculation of smoke originating within the
surgical suite, and (iii) Prevents the circulation of smoke entering the
system intake. These requirements would impact the design,
installation, and operation of the entire HVAC system for a facility.
Occupational Exposure to Bloodborne Pathogens
29CFR 1910.1030
http://www.osha.gov/pls/oshaweb/owadisp.show_doc
ument?p_table=standards&p_id=10051


OSHA has two different types of inspections:
• Enforcement inspections determined by OSHA
(unannounced)
• Consultation services that are requested by the facility
(scheduled)
http://www.osha.gov/dcsp/smallbusiness/consult.htm

These surveys focus on the ASC’s response to
recalls.
http://www.fda.gov/Safety/Recalls/default.htm
http://www.fda.gov/Safety/MedWatch/default.htm

Resource Conservation and Recovery Act (RCRA)
gives the EPA the authority to control hazardous
waste from the “cradle to the grave”. This includes
the generation, transportation, treatment, storage,
and disposal of hazardous waste.

Hazardous Pharmaceutical Waste under the RCRA:
• Contains a “P” (acutely hazardous) or “U” (toxic) listed
waste as the sole ingredient; or
• Exhibits at least one “characteristic” of a hazardous waste

It is recommended to involve the center’s consulting
pharmacist to make certain the center is in compliance
with federal and state regulations.

Questions and Answers regarding DEA 222
formshttp://www.deadiversion.usdoj.gov/faq/dea2
22.htm

These surveys examine:
• the process of transporting radioactive materials
• training of ASC staff in handling radioactive
materials
• the ASC’s policies on radioactive materials (process
for shipping of materials, process for return of
product, how to handle hazards, staff training,
consultant physicist, etc.)
Rule Reference
Proposed or
Final Rule
Federal Register (FR) Reference
https://www.federalregister.gov
Program Highlights
CY 2015
OPPS/ASC
Final
1 new claims-based
measure- “dry run” 2015
CY 2014
OPPS/ASC
Final
78 FR 75122
Finalized 3 measures
CY 2013
OPPS/ASC
Final
77 FR 68492
No additional measures
FY 2013
IPPS/LTCH PPS
Final
77 FR 53637
Finalized requirements
CY 2012
OPPS/ASC
Final
76 FR 74492
Finalized 8 measures
CY 2011
OPPS/ASC
Final
75 FR 72109
Discussed/Not
implemented
CY 2010
OPPS/ASC
Final
74 FR 60656
Discussed/Not
implemented
CY 2009
OPPS/ASC
Final
73 FR 68780
Discussed/Not
implemented
CY 2008
OPPS/ASC
Final
72 FR 66875
Discussed/Not
implemented
Number
ASC-1
ASC-2
ASC-3
ASC-4
ASC-5
ASC-6
ASC-7
ASC-8
Measure Title
Patient Burn
Type of
Measure
Claims-Based
Data Collection
Date
Data Reporting
Date
January 1January 1December 31,
December 31,
2014
2014
Patient Fall
Claims-Based
January 1January 1December 31,
December 31,
2014
2014
Wrong Site, Wrong Side,
Claims-Based
January 1January 1Wrong Patient, Wrong
December 31,
December 31,
Procedure,Wrong Implant
2014
2014
Hospital
Claims-Based
January 1January 1Transfer/Admission
December 31,
December 31,
2014
2014
Prophylactic Intravenous
Claims-Based
January 1January 1(IV) Antibiotic Timing
December 31,
December 31,
2014
2014
Safe Surgery Checklist Use Web-Based via
January 1January 1QualityNet
December 31,
August 15, 2015
secure portal
2014
ASC Facility Volume Data Web-Based via
January 1January 1on Selected ASC Surgical
QualityNet
December 31,
August 15, 2015
Procedures
secure portal
2014
Influenza Vaccination
Web-Based October 1, 2014- through May 15,
Coverage among
via NHSN
March 31, 2015
2015
Healthcare Personnel
Affected Groups
Medicare Part B fee for service
patients
Medicare Part B fee for service
patients
Medicare Part B fee for service
patients
Medicare Part B fee for service
patients
Medicare Part B fee for service
patients
All patients
All patients
Health Care
Personnel
Number
ASC-9
ASC-10
ASC-11 Voluntary
ASC-12
Measure Title
Type of
Measure
Data Collection
Date
Data Reporting
Date
Endoscopy/Polyp
Web-Based via
April 1January 1Surveillance: Appropriate
QualityNet
December 31,
August 15, 2015
Follow-Up Interval for
secure portal
2014
Normal Colonoscopy in
Average Risk Patients
Endoscopy/Polyp
Web-Based via
April 1January 1Surveillance: Colonoscopy
QualityNet
December 31,
August 15, 2015
Interval for Patients with a secure portal
2014
History of Adenomatous
Polyps – Avoidance of
Inappropriate Use
Cataracts- Improvement in Web-Based via
January 1,January 1, August
Patient’s Visual Function
QualityNet
December 31,
15, 2016
within 90 days following
secure portal
2015
Cataract Surgery
Facility Seven-Day Risk
Claims-Based
Paid Medicare
Paid Medicare
Standardized Hospital Visit
Fee for Service
Fee for Service
Rate after Outpatient
Claims from
Claims from
Colonoscopy
January 1, 2016 January 1, 2016 –
– December 31,
December 31,
2016
2016
Affected Groups
Sampling
Sampling
Sampling
Paid Medicare Fee
for Service Claims

CMS ASC Quality Reporting Program Quality
Measures Specifications Manual
 To date- 9 versions (April 2012-June 2014)
 Latest version- 4.0 (June 2014)
• Located @ www.qualitynet.org under ASC tab
• Included in this manual:
 Measure specifications
 Data collection and submission
 Quality Data Codes (QDCs)

•
•
•
•
ASC-1: Patient Burn*
ASC-2: Patient Fall*
ASC-3: Wrong Site, Wrong Side, Wrong
Patient, Wrong Procedure, Wrong Implant*
ASC-4: Hospital Transfer/Admission*
ASC-5: Prophylactic Intravenous (IV)
Antibiotic Timing*
*Data submission began in CY 2012

Claims Based Reporting–Quality Data Codes (QDCs)
•
•
•
•
•

Patient Burn
Patient Fall
Wrong Site, Side, Patient, Procedure, Implant
Hospital Admission/Transfer
Prophylactic IV Antibiotic Timing
Web Based Reporting via QualityNet Secure Portal
(www.qualitynet.org)
• Safe Surgery Check List Use
• ASC Volume of Selected Procedures for all-patients

Web Based Reporting Via Centers for Disease Control
and Prevention (CDC) National Health Care Safety
Network (NHSN) (www.cdc.gov/nhsn/index.html)
• Influenza Vaccination Coverage Among Health Care Personnel
The ASC quality measures, G codes, and their descriptions are included in Table 6 below:
ASC Quality Measures
G-code Long Descriptor
Patient documented not to have experienced any of the following events: a burn
prior to discharge; a fall within the facility; wrong
site/side/patient/procedure/implant event; or a hospital transfer or hospital
G8907 admission upon discharge from the facility.
Patient burn
G8908 Patient documented to have received a burn prior to discharge
G8909 Patient documented not to have received a burn prior to discharge
Patient fall in ASC facility
G8910 Patient documented to have experienced a fall within ASC
Patient documented not to have experienced a fall within Ambulatory Surgical
G8911 Center
Wrong site, wrong side, wrong
patient, wrong procedure, wrong
Patient documented to have experienced a wrong site, wrong side, wrong patient,
implant
G8912 wrong procedure or wrong implant event
Patient documented not to have experienced a wrong site, wrong side, wrong
G8913 patient, wrong procedure or wrong implant event
Patient documented to have experienced a hospital transfer or hospital admission
Hospital transfer/Admission
G8914 upon discharge from ASC
Patient documented not to have experienced a hospital transfer or hospital
G8915 admission upon discharge from ASC
Timing of Prophylactic antibiotic
administration for SSI prevention G8916
G8917
G8918
Patient with preoperative order for IV antibiotic surgical site infection (SSI)
prophylaxis, antibiotic initiated on time
Patient with preoperative order for IV antibiotic surgical site infection (SSI)
prophylaxis, antibiotic not initiated on time
Patient without preoperative order for IV antibiotic surgical site infection (SSI)
prophylaxis



Released August 2012
The final rule can be accessed at
(https://s3.amazonaws.com/publicinspection.federalregister.gov/2012-19079.pdf)
This is the vehicle for rulemaking on the specifics of the ASC
quality reporting program; ASC information begins on page
1534; Section E.
◦
◦
◦
◦
◦
Participation in the ASC Quality Reporting Program; Page 1540
Limited details for public reporting of data; Page 1541
Data completeness and validation; Page 1548
Extraordinary circumstances; Page 1554
Reconsideration and appeals process; Page 1558



Once an ASC submits any quality measure data, the center
would be considered participating
The ASC will continue to be considered a participant, regardless
of whether the ASC continues to submit quality measure data,
until formally withdrawing from the program
An ASC that wishes to withdraw from the ASC Quality Reporting
(ASCQR) Program must fill out an online withdrawal form:
• Located on the QualityNet website www.qualitynet.org
• Click on left hand side: how to participate then
• Click on left hand side: how to withdraw


An ASC can withdraw at any time up to August 31 prior to the
payment determination year
An ASC that withdraws will incur a 2% reduction in its Annual
Payment Update (APU) and any subsequent year the ASC is not
participating





Process was established in the FY 2013 IPPS/LTCH PPS final
rule (77 FR 53642 through 53643)
CMS may grant a waiver or extension to ASCs for data
submission requirements if it is determined that a systemic
problem with a data collection system directly or indirectly
affects the ability to enter data
Needs to be submitted within 45 days of the extraordinary
circumstance
Form (Extraordinary Circumstances) is located on
www.qualitynet.org; click on ASC tab; form is located on
the left side of the page
In the future this process will be referred to as the
Extraordinary Circumstances Extensions or Exemptions
Process




Process was established in the FY 2013 IPPS/LTCH PPS
final rule (77 FR 53643 through 53644)
Reconsideration request form must be submitted by
March 17 of the affected payment year
CMS intends to complete any reconsideration reviews
and communicate results within 90 days following the
deadline (March 17 of the affected payment year)
Form (Annual Payment Update (APU) reconsideration)
is located on www.qualitynet.org; click on ASC tab;
form is located on the left side of the page
ASC-1: Patient Burn
 ASC-2: Patient Fall
 ASC-3: Wrong Site, Wrong Side, Wrong Patient,
Wrong Procedure, Wrong Implant
 ASC-4: Hospital Transfer/Admission
 ASC-5: Prophylactic Intravenous (IV) Antibiotic
Timing
 ASC-6: Safe Surgery Checklist Use
 ASC-7: ASC Facility Volume Data on Selected ASC
Surgical Procedures {Procedure Category Corresponding

HCPCS Codes:
Eye/Gastrointestinal/Genitourinary/Musculoskeletal/
Nervous/Respiratory/Skin/Multi-system}
Safe Surgery Checklist Use
 Intent: Assess whether an ASC uses a safe surgery
checklist
 May employ any checklist as long as it addresses
effective communication and safe surgery practices
in each of three peri-operative periods:
• the period prior to the administration of anesthesia,
• the period prior to skin incision, and
• the period of closure of incision and prior to the patient leaving the
operating room

Applies to all ASCs
Safe Surgery Checklist Use
 Data collection: January 1-December 31, 2014
 For 2014 and beyond, the checklist should be
utilized for the ENTIRE year for an answer of
"Yes".
 Report “Yes” or “No” on the Quality Net web
site (www.qualitynet.org) between January 1
through August 15, 2015.
ASC Volume of Selected Procedures

Intent: Measure all patient volume of procedures performed in one
of eight categories
•
•
•
•
•
•
•
•


Eye
Gastrointestinal
Genitourinary
Musculoskeletal
Nervous System
Respiratory
Skin
Multi-system
Measurement from January 1, 2014 through December 31, 2014
Report volumes for entire 2014 calendar year on the QualityNet
web site (www.qualitynet.org) between January 1 thru August 15,
2015
Organ System
CMS Procedure Category
Surgical Procedure Codes
Eye
Organ transplant (eye)
65756, V2785
Laser procedure of eye
65855, 66761, 66821
Glaucoma procedures
66170, 66180 , 66711
Cataract procedures
66982, 66984
Injection of eye
67028, J2778, J3300, J3396
Retina, macular and posterior segment procedures
67041, 67042, 67210, 67228
Repair of surrounding eye structures
15823, 67900, 67904, 67917, 67924
GI endoscopy procedures
43239, 43235, 43248, 43249, 43251,
44361, 45330, 45331, 45378, 45380,
45381, 45383, 45384, 45385 ,46221
Swallowing tube (esophagus)
43450
Hernia repair
49505
GI screening procedures
G0105, G0121
Gastrointestinal
Organ System
CMS Procedure Category
Surgical Procedure Codes
Genitourinary
Kidney stone fragmentation
50590
Bladder related procedures
52000, 52005, 52204, 52281,
52310, 52332
Prostate biopsy
55700
Radiologic procedures (GU)
74420
Ultrasound procedures (GU)
76872
Joint or muscle aspiration or injection
20610
Removal of musculoskeletal implants
20680
Repair of tendons and ligaments
23412
Repair of foot, toes, fingers, and wrist
26055, 28270, 28285, 28296,
29848
Removal of musculoskeletal lesion
26160
Joint arthroscopy
29824, 29826, 29827, 29880,
29881 , 29823, 29822
Musculoskeletal drug injection
J0585, J0878, J0131
Musculoskeletal
Organ System
CMS Procedure Category
Surgical Procedure Codes
Nervous
Injection procedures in or around the spine
62310, 62311, 64479, 64480,
64483, 64484, 64490, 64491,
64492, 64493, 64494, 64495,
64622, 64623, 64626, 64627,
64633, 64634, 64635, 64636,
64640, G0260 , J2278
Device implant
63650
Nerve decompression
64718
Repair of foot, toes, fingers, and wrist
64721
Respiratory
Sinus procedure
30140, 31255, 31267
Skin
Skin procedures including debridement,
reconstructive, wound closure, excision and/or
repair
11042, 13132, 14040, 14060,
15260, 17311, Q4101, Q4102,
Q4106
Multi-system*
Brachytherapy
Cancer treatment with angiogenesis inhibitor
C2638, C2639, C2640, C2641
C9257
*Multi-System: procedures that can be performed in
more than one organ system.

Claims Based Reporting–Quality Data Codes (QDCs)
•
•
•
•
•

Patient Burn
Patient Fall
Wrong Site, Side, Patient, Procedure, Implant
Hospital Admission/Transfer
Prophylactic IV Antibiotic Timing
Web Based Reporting via QualityNet Secure Portal
(www.qualitynet.org)
• Safe Surgery Check List Use
• ASC Volume of Selected Procedures for all-patients

Web Based Reporting Via Centers for Disease Control
and Prevention (CDC) National Health Care Safety
Network (NHSN) (www.cdc.gov/nhsn/index.html)
• Influenza Vaccination Coverage Among Health Care Personnel

Web Based Reporting via QualityNet Secure
Portal (www.qualitynet.org)
• Safe Surgery Check List Use
• ASC Volume of Selected Procedures for all-patients



No reporting for these two measures for 2013
Data Collection for these two measures will
resume January 1 - December 31, 2014
Data Reporting for calendar year 2014 will be
from January 1- August 15, 2015
ASC Program Measurement Set for the CY 2016 Payment Determination
 ASC-1: Patient Burn
 ASC-2: Patient Fall
 ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure,
Wrong Implant
 ASC-4: Hospital Transfer/Admission
 ASC-5: Prophylactic Intravenous (IV) Antibiotic Timing
 ASC-6: Safe Surgery Checklist Use
 ASC-7: ASC Facility Volume Data on Selected ASC Surgical Procedures
{Procedure Category Corresponding HCPCS Codes:
Eye/Gastrointestinal/Genitourinary/Musculoskeletal/
Nervous/Respiratory/Skin/Multi-system}
 ASC- 8: Influenza Vaccination Coverage among Healthcare Personnel *
*New measure for CY 2016 payment determination
Influenza Vaccination Coverage among
Healthcare Personnel (HCP)


Intent: assess the percentage of HCP immunized for influenza
during the flu season
3 Categories of Healthcare Personnel will include:
• Employee on facility payroll
• Licensed independent practitioners, e.g. physicians (MDs, DO), advance
practice nurses and physician assistants who are affiliated with the facility
who do not receive a direct paycheck from the facility
• Adult students/trainees and volunteers who do not receive a direct
paycheck from the facility




Data collection begins with immunizations for the flu
season October 1, 2014 through March 31, 2015
CDC’s NHSN website for enrollment:
www.cdc.gov/nhsn/ambulatory-surgery/enroll.html
◦ “NHSN facility administrator enrollment guide” (step by
step)
Deadline for data submission for the 2014-2015 flu
season through May 15, 2015.
 Review
and accept the NHSN rules of
behavior
 Register with SAMS
 SAMS = Secure Access Management
Services, a federal information technology
(IT) system that gives authorized personnel
secure access to non-public CDC
applications




Users must fax or mail notarized proof of identity to
CDC.
You will receive a grid card in the mail in order to
access NHSN.
Complete and submit required forms (facility
information, facility survey, consent form)
Reporting (https://sams.cdc.gov ) user authorization
through Secure Access Management Services (SAMS)
is required for access to NHSN.
Employee HCP
Non-Employee HCP
Employees (staff Licensed independent
on facility payroll)
practitioners:
Physicians, advanced
practice nurses, &
physician assistants
1. Number of HCP who worked at this
healthcare facility for at least 1 day
between October 1 and March 31
2. Number of HCP who received an influenza
vaccination at this healthcare facility since
influenza vaccine became available this
season
3. Number of HCP who provided a written
report or documentation of influenza
vaccination outside this healthcare facility
since influenza vaccine became available
this season
4. Number of HCP who have a medical
contraindication to the influenza vaccine
5. Number of HCP who declined to receive
the influenza vaccine
6. Number of HCP with unknown
vaccination status (or criteria not met for
questions 2-5 above
Adult students/
trainees &
volunteers
Other contract
personnel



Employee HCP
Non-Employee HCP: Licensed independent
practitioners (physicians, advance practice nurses,
and physician assistants)
Non-Employee HCP: Adult students/trainees and
volunteers
41

Influenza
vaccinations
◦ Received at this
healthcare facility
◦ Received elsewhere



Medical
contraindications
Declinations
Unknown status
 10 + 20 + 15 + 5 + 5 = 55
 70 + 10 + 10 + 5 + 5 = 100
 20 + 2 + 1 + 1 + 1 = 25

Claims Based Reporting–Quality Data Codes (QDCs)
•
•
•
•
•

Patient Burn
Patient Fall
Wrong Site, Side, Patient, Procedure, Implant
Hospital Admission/Transfer
Prophylactic IV Antibiotic Timing
Web Based Reporting via QualityNet Secure Portal
(www.qualitynet.org)
• Safe Surgery Check List Use
• ASC Volume of Selected Procedures for all-patients

Web Based Reporting Via Centers for Disease Control
and Prevention (CDC) National Health Care Safety
Network (NHSN) (www.cdc.gov/nhsn/index.html)
• Influenza Vaccination Coverage Among Health Care Personnel



The CDC conducted live training webinars in August to
cover the requirements for collecting and entering HCP
influenza vaccination summary data.
A recording of the webinar has been posted at:
http://www2.cdc.gov/vaccines/ed/nhsn/, so staff can
review the recorded training and slides.
For questions on HCP influenza vaccination summary
reporting, please send an e-mail to:
[email protected] and include “HPS Flu Summary-ASC” in
the subject line.
Released on November 27, 2013
 www.gpo.gov/fdsys/pkg/FR-2013-12-10/pdf/201328737.pdf
• ASC Quality Reporting Program begins on page 974 ;
Section XV. Requirements for ASC Quality Reporting
Program

• 3 Quality Measures for CY 2016: page 979
• 50% minimum reporting threshold: page 1025
• Exempting low volume providers: page 1027
(less than 240 Medicare claims/year)


Previous ASC 1- ASC 8 plus
3 Additional Measures:
• Endoscopy/Poly Surveillance: Appropriate follow-up interval
for normal colonoscopy in average risk patients (NQF
#0658);
• Endoscopy/Poly Surveillance: Colonoscopy Interval for
Patients with a History of Adenomatous Polyps – Avoidance
of Inappropriate Use (NQF #0659); and
• Cataracts: Improvement in Patient’s Visual Function within
90 Days Following Cataract Surgery (NQF #1536).
* NQF= National Quality Forum (www.qualityforum.org)


Denominator: patients aged 50 years and older
receiving screening colonoscopy without biopsy or
polypectomy
Numerator: patients who had a recommended
follow- up interval of 10 years for repeat
colonoscopy documented in their colonoscopy
report*
*follow-up interval is at least 10 years from the date of the
current colonoscopy
*physician’s documentation in the colonoscopy report

Exclusions: documentation of medical reasons for not
recommending at least a 10-year follow-up (above average risk,
inadequate prep)

Inclusions:
Patients aged ≥ 50 on date of encounter
And
ICD-9-CM Diagnosis code: V76.51
And
CPT or HCPCS: 45378, G0121
Without
CPT Category I Modifiers: 52, 53, 73, 74
Without
ICD-9-CM Diagnosis codes: V18.51, V12.72, V16.0, V10.05
(The ICD-9 codes will be updated when the conversion to ICD-10
occurs)

Denominator: number of patients 18 years and
older receiving a surveillance colonoscopy with a
history of a prior colonic polyp in a previous
colonoscopy

Numerator: number of patients who had an
interval of three or more years since their last
colonoscopy*
*Information regarding performance interval can be obtained from the
medical record.

Exclusions:
• Documentation of medical reason(s) for an interval of
less than three years since the last colonoscopy (for
example, last colonoscopy incomplete, last
colonoscopy had inadequate prep, piecemeal removal
of adenomas, or last colonoscopy found greater than
10 adenomas)
• Documentation of a system reason(s) for an interval
less than three years since last colonoscopy (for
example, unable to locate previous colonoscopy
report, previous colonoscopy report was incomplete)

Inclusions:
Patients aged ≥ 18 years on date of encounter
And
Diagnosis for history of colonic polyp(s) (ICD-9-CM): V12.72,
V10.05
And
CPT or HCPCS: 44388, 44389, 44392, 44393, 44394, 45355,
45378, 45380, 45381, 45383, 45384, 45385, G0105
Without
CPT Category I Modifiers: 52, 53, 73 or 74
(The ICD-9 codes will be updated when the conversion to ICD-10 occurs)

Denominator: number of patients aged 18 years and
older in sample who had cataract surgery and
completed both a pre-operative and post-operative
visual function instrument

Numerator: number of patients 18 years and older
who had improvement in visual function achieved
within 90 days following cataract surgery, based on
completing both a pre-operative and post-operative
visual function instrument
Examples of tools for visual function assessment include, but are not
limited to:
National Eye Institute-Visual Function Questionnaire – VFQ-25
www.rand.org/health/surveys_tools/vfq.html
 Visual Function (VF)-14
www.med.teikyo-u.ac.jp/~ortho/med/reh/VF-14.html
 Modified VF-8
http://ascrs.org/sites/default/files/resources/2013%20Cataracts%20Measure
s%20Group%20Post-Surgery%20VF-8R_0.pdf
 Modified Catquest-9
http://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/OPX/
A/OPX_90_8_2013_04_04_LUNDSTROM_201940_SDC1.pdf

55
Population Per Year
Yearly Sample Size
Quarterly Sample Size
Monthly Sample Size
0-900
63
16
6
Population Per Year
Yearly Sample Size
Quarterly Sample Size
Monthly Sample Size
≥901
96
24
8
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Claims Based Reporting–Quality Data Codes (QDCs)
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•
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•
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Patient Burn
Patient Fall
Wrong Site, Side, Patient, Procedure, Implant
Hospital Admission/Transfer
Prophylactic IV Antibiotic Timing
Web Based Reporting via QualityNet Secure Portal (www.qualitynet.org)
• Safe Surgery Check List Use
• ASC Volume of Selected Procedures for all-patients
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Web Based Reporting Via Centers for Disease Control and Prevention (CDC)
National Health Care Safety Network (NHSN)
(www.cdc.gov/nhsn/index.html)
• Influenza Vaccination Coverage Among Health Care Personnel
Web Based Reporting via QualityNet Secure Portal (www.qualitynet.org)
• Endoscopy/Polyp Surveillance (normal)
• Endoscopy/Polyp Surveillance (adenomatous)
• Cataract: improvement in visual function- voluntary
Released on October 31, 2014
• http://www.ofr.gov/(S(j4muxl5s4vqongwcshdlh533))/O
FRUpload/OFRData/2014-26146_PI.pdf
• ASC Quality Reporting Program begins on page 781:
Section XIV. Requirements for ASC Quality Reporting
Program
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Previous ASC 1- ASC 10 plus
ASC 11: Cataracts: Improvement in Patient’s Visual
Function within 90 Days Following Cataract Surgery (NQF
#1536) voluntary
NQF = National Quality Forum (www.qualityforum.org)
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Previous ASC 1- ASC 10 plus
ASC 11: Cataracts: Improvement in Patient’s Visual
Function within 90 Days Following Cataract Surgery (NQF
#1536) voluntary
1 Additional Measure:
ASC 12: Facility Seven-Day Risk-Standardized Hospital
Visit Rate after Outpatient Colonoscopy
NQF = National Quality Forum (www.qualityforum.org)
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Claims based measure
No additional data submission from ASCs
The measure outcome is all unplanned hospital
visits (admissions, observation stays, and
emergency department [ED] visits) within 7 days
of the procedure.
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In 2015, Medicare will perform a “dry run” of this
measure.
A dry run is a preliminary analysis of data in
which ASCs may review their measure results,
and ask questions about and become familiar
with the measure methodology.
The most recent complete claims samples
(usually 6-9 months prior to the start date) for
dry runs will be used.
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The dry run will generate confidential reports at the
patient level, indicating whether the patient had a
hospital visit, the type of visit (admission, ER visit, or
observational stay), the admitting facility, and the
principal discharge diagnosis.
The ASC will have the opportunity to receive individual
patient data and information contained within individual
patient records in order to identify performance gaps
and develop quality improvement strategies.
Dry runs results ARE NOT linked to public reporting or
payment determinations.
ASCs can review their confidential dry run reports at
www.qualitynet.org.
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For the CY 2018 payment determination, paid
Medicare Fee For Service claims from January 1 –
December 31, 2016 will be used (calendar years
2 years before the payment determination
calendar year.
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Patient experience of care: ASC Consumer Assessment
of Healthcare Providers and Systems (CAHPS) patient
experience survey
Care Plan- (percentage of patients 65 years and older
who have a care plan or surrogate decision
documented in the medical record)
Hair removal
Normothermia
Unplanned anterior vitrectomy
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ASC Quality Collaboration website (measure summary and
implementation guide)http://ascquality.org/qualitymeasures.cfm
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Ambulatory Surgery Center Association (ASCA)
http://www.ascassociation.org
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QualityNet website
(CMS Specifications Manual & Email Notifications)
http://qualitynet.org

FMQAI website (CMS national support contractor)
http://oqrsupport.org
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CMS certification number (CCN) Look-Up Tool (allows a facility to enter its
National Provider Identifier (NPI) in the search box to find its CCN)
http://www.oqrsupport.com/asc/ccn
Contact FMQAI for Program Questions at
[email protected]
or via phone (866) 800-8756
Monday through Friday,
7 a.m. to 6 p.m. Eastern Time
Contact the QualityNet Help Desk for Technical Issues at
[email protected]
or via phone (866) 288-8912
Monday through Friday,
7 a.m. to 7 p.m. Central Time
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Federal Register / Vol. 76, No. 230 / Wednesday, November 30, 2011 / Rules and Regulations.
Available at http://www.gpo.gov/fdsys/pkg/FR-2011-11-30/pdf/2011-28612.pdf
Federal Register / Vol. 77, No. 170 / Friday, August 31, 2012/ Rules and Regulations. Available at
http://www.gpo.gov/fdsys/pkg/FR-2012-08-31/pdf/2012-19079.pdf
Federal Register / Vol. 77, No. 221 / Thursday, November 15, 2012 / Rules and Regulations. Available
at http://www.gpo.gov/fdsys/pkg/FR-2012-11-15/pdf/2012-26902.pdf
Federal Register / Vol. 78, No. 237 / Tuesday, December 10, 2013/ Rules and Regulations. Available at
http://www.gpo.gov/fdsys/pkg/FR-2013-12-10/pdf/2013-28737.pdf
Federal Register / Vol. 79, No. 134 / Monday, July 14, 2014/ Rules and Regulations. Available at
http://www.gpo.gov/fdsys/pkg/FR-2014-07-14/pdf/2014-15939.pdf
ASC Quality Collaboration Implementation Guide, Version 2.1, April 2014. Available at
http://ascquality.org/documents/ASCQC.Implementation.Guide.2.1April2014.pdf
CMS ASC Quality Reporting Program Quality Measures Specifications Manual, Version 4.0, June 2014.
Available at www.qualitynet.org
Quality Net at www.qualitynet.org
National Healthcare Safety Network www.cdc.gov/nhsn/
http://www.ofr.gov/(S(j4muxl5s4vqongwcshdlh533))/OFRUpload/OFRData/2014-26146_PI.pdf
Gina Throneberry, RN, MBA, CASC, CNOR
Ambulatory Surgery Center Association (ASCA)
Director or Education and Clinical Affairs
[email protected]

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