cms quality measure repor6ng update...asc-14 unplanned anterior vitrectomy december 31, web-based...
TRANSCRIPT
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Keeping you “in the know” in the ASC industry
CMSQualityMeasureRepor6ngUpdate
GinaThroneberry,RN,MBA,CASC,CNORDirectorofEduca6onandClinicalAffairs
AmbulatorySurgeryCenterAssocia6on(ASCA)
ASCQRProgramMeasuresSummary
Number MeasureTitle TypeofMeasure
DataCollectionDates
DataReportingDates
PaymentDetermination
Year
MeasureApplies
To
ASC-1 PatientBurn Claims-Based January1-December31,2017
January1-December31,2017
CY2019 MedicarePartBfeeforservicepatients
January1-December31,2018
January1-December31,2018
CY2020
ASC-2 PatientFall Claims-Based January1-December31,2017
January1-December31,2017
CY2019 MedicarePartBfeeforservicepatients
January1-December31,2018
January1-December31,2018
CY2020
ASC-3 WrongSite,WrongSide,WrongPatient,WrongProcedure,WrongImplant
Claims-Based January1-December31,2017
January1-December31,2017
CY2019 MedicarePartBfeeforservicepatients
January1-December31,2018
January1-December31,2018
CY2020
ASC-4 HospitalTransfer/Admission
Claims-Based January1-December31,2017
January1-December31,2017
CY2019 MedicarePartBfeeforservicepatients
January1-December31,2018
January1-December31,2018
CY2020
ASC-5 ProphylacticIntravenous(IV)AntibioticTiming
Claims-Based January1-December31,2017
January1-December31,2017
Noreportingin2018
MeasureremovedforCY2019
MedicarePartBfeeforservicepatients
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ASCQRProgramMeasuresSummary
Number MeasureTitle TypeofMeasure
DataCollectionDates
DataReportingDates
PaymentDetermination
Year
MeasureAppliesTo
ASC-6 SafeSurgeryChecklistUse
Web-BasedviaQualityNetsecureportal
January1-December31,2017
January1-May15,2018Noreportingin
2018
MeasureRemovedforCY2019
Allpatients
ASC-7 ASCFacilityVolumeDataonSelectedASCSurgicalProcedures
Web-BasedviaQualityNetsecureportal
January1-December31,2017
January1-May15,2018Noreportingin
2018
MeasureRemovedforCY2019
Allpatients
ASC-8 InfluenzaVaccinationCoverageamongHealthcarePersonnel
Web-BasedviaNationalHealthcare
SafetyNetwork(NHSN)
October1,2017March31,2018
ThroughMay15,2018
CY2019 HealthCarePersonnel
October1,2018March31,2019
ThroughMay15,2019
CY2020 HealthCarePersonnel
ASCQRProgramMeasuresSummary
Number MeasureTitle TypeofMeasure
DataCollectionDates
DataReportingDates
PaymentDetermination
Year
MeasureApplies
ToASC-9 Endoscopy/PolypSurveillance:
AppropriateFollow-UpIntervalforNormalColonoscopyinAverageRiskPatients
Web-BasedviaQualityNetsecureportal
January1-December31,2017
January1-May15,2018 CY2019 Sampling
January1-December31,2018
January1-May15,2019 CY2020
ASC-10 Endoscopy/PolypSurveillance:ColonoscopyIntervalforPatientswithaHistoryofAdenomatousPolyps–AvoidanceofInappropriateUse
Web-BasedviaQualityNetsecureportal
January1-December31,2017
January1-May15,2018 CY2019 Sampling
January1-December31,2018
January1-May15,2019 CY2020
ASC-11Voluntary
Cataracts-ImprovementinPatient’sVisualFunctionwithin90daysfollowingCataractSurgery
Web-BasedviaQualityNetsecureportal
January1-December31,2017
January1-May15,2018 CY2019 Sampling
January1-December31,2018
January1-May15,2019 CY2020
ASC-12 FacilitySeven-DayRiskStandardizedHospitalVisitRateafterOutpatientColonoscopy
AdministrativeClaims-Based
PaidMedicareFeeforServiceClaims
January1-December31,2017andsubsequent
years
PaidMedicareFeeforServiceAdministrative
ClaimsPreviewReportswereavailableforreviewon
QualityNet
CY2019 PaidMedicareFeeforServiceClaims
ASCQRProgramMeasuresSummary
Number MeasureTitle TypeofMeasure
DataCollectionDates
DataReportingDates
PaymentDetermination
Year
MeasureApplies
To
ASC-13 Normothermia Web-basedviaQualityNetsecureportal
January1-December31,
2018
January1-May15,2019
CY2020 Sampling
ASC-14 UnplannedAnteriorVitrectomy
Web-basedviaQualityNetsecureportal
January1-December31,
2018
January1-May15,2019
CY2020 AllPatientsMeetingCriteria
ASC-15(15a-e)
OutpatientandAmbulatorySurgeryConsumerAssessmentofHealthcareProvidersandSystems(OASCAHPS
SurveyAdministered
byanapprovedvendor
January1-December31,
2018Delayed
QuarterlybyCMSapproved
vendor
CY2020Delayed
AllPatientswithExclusions300CompletedSurveysviaApprovedVendor
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ASCQRProgramMeasuresSummary
Number MeasureTitle TypeofMeasure
DataCollectionDates
DataReportingDates
PaymentDetermination
Year
MeasureApplies
To
ASC-16NotFinalized
ToxicAnteriorSegmentSyndrome(TASS)
Web-basedviaQualityNetsecureportal
January1-December31,
2019
January1-May15,2020
CY2021 AllPatientsMeetingCriteria
ASC-17Final
HospitalVisitAfterOrthopedicAmbulatorySurgeryProcedures
AdministrativeClaimsBased
PaidMedicareFeeforServiceClaims
January1-December31,2020
PaidMedicareFeeforServiceAdministrative
Claims
CY2022 PaidMedicareFeeforServiceClaims
ASC-18Final
HospitalVisitAfterUrologyAmbulatorySurgeryProcedures
AdministrativeClaimsBased
PaidMedicareFeeforServiceClaims
January1-December31,2020
PaidMedicareFeeforServiceAdministrative
Claims
CY2022 PaidMedicareFeeforServiceClaims
CMSAmbulatorySurgicalCenterQualityRepor6ngProgram
• CMSASCQualityRepor6ngProgramQualityMeasuresSpecifica6onsManual• Verifyyouhavethelatestversions
– 7.0a 1Q18-4Q18(released12/8/17)– 6.0a 1Q17-4Q17
• [email protected]• Includedinthismanual:
• Measurespecifica6ons• Datacollec6onandsubmission• QualityDataCodes(QDCs)
ASCQualityRepor6ngProgramMeasures
• ASC-1:Pa6entBurn• ASC-2:Pa6entFall• ASC-3:WrongSite,WrongSide,WrongPa6ent,Wrong
Procedure,WrongImplant• ASC-4:HospitalTransfer/Admission• ASC-5:Prophylac6cIntravenous(IV)An6bio6cTiming(norepor6ngin2018)
MedicarePartBFeeforServicePa1entsClaimsBasedRepor6ng–QualityDataCodes(QDCs)
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ASCQualityRepor6ngProgramMeasures
• ASC-6:SafeSurgeryChecklistUse(norepor6ngin2018)• ASC-7:ASCFacilityVolumeDataonSelectedASCSurgicalProcedures
(norepor6ngin2018)• ASC-9:Endoscopy/PolypSurveillance:AppropriateFollow-UpIntervalforNormal
ColonoscopyinAverageRiskPa6ents• ASC-10:Endoscopy/PolypSurveillance:ColonoscopyIntervalforPa6entswithaHistory
ofAdenomatousPolyps-AvoidanceofInappropriateUse
WebBasedRepor;ngviaQualityNetSecurePortal(www.qualitynet.org)• Datacollec%on:January1throughDecember31,2017• Datarepor%ng:January1throughMay15,2018
• Datacollec%on:January1throughDecember31,2018• Datarepor%ng:January1throughMay15,2019
ASCQualityRepor6ngProgramMeasures
ASC-8:InfluenzaVaccina6onCoverageamongHealthcarePersonnel
WebBasedRepor;ngViaCentersforDiseaseControlandPreven;on(CDC)Na;onalHealthCareSafetyNetwork(NHSN)(www.cdc.gov/nhsn/index.html)
• Datacollec%onbeginswithimmuniza6onsforthefluseason
October1,2017throughMarch31,2018• Deadlinefordatarepor%ngforthe2017-2018fluseasonisMay
15,2018.
ASCQualityRepor6ngProgramMeasuresASC-8:InfluenzaVaccina6onCoverageamongHealthcarePersonnel
• InDecember2017NHSNusersneededtoacceptanupdatedNHSNAgreementtoPar6cipateandConsent,evenifyouhadsubmigedonepreviously.
• ThisnewformshouldhavebeensubmigedelectronicallythroughNHSN.• Yourfacility’sprimarycontactwasrequiredtoacceptthenewformby
April14,2018oryouwouldnotbeabletosubmitdatainNHSNforASC-8.• NHSNfunc6onalitywillbedisabledun6ltheconsentformisacceptedby
yourfacility’sprimarycontact.
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ASCQualityRepor6ngProgramMeasures
ASC-12:FacilitySeven-DayRisk-StandardizedHospitalVisitRateajerOutpa6entColonoscopy• DataispulledbyCMSfromtheMedicareFeeforService
administra1veclaimsthatwerebilledbythecenterstar6ngJanuary1-December31,2016andsubsequentyears.
• Nodatasubmissionorrepor6ngrequiredfromtheASC• ColonoscopyClaimsDetailReports(CDR)willbeperiodically
uploadedtotheQualityNetsecureportalthroughouttheyear.
• ASC13NormothermiaOutcomeDatasubmigedforaSamplingthatmeetthedenominatorcriteria.
• ASC14UnplannedAnteriorVitrectomy DatasubmigedforAllPa%entsthatmeetthedenominator
criteria.WebBasedRepor;ngviaQualityNetSecurePortal(www.qualitynet.org)
• Datacollec%on:January1throughDecember31,2018• Datarepor%ng:January1throughMay15,2019
ASCQualityRepor6ngProgramMeasures
ASC13:NormothermiaOutcome
Numerator:Surgerypa6entswithabodytemperatureequaltoorgreaterthan96.8Fahrenheit/36CelsiusrecordedwithinfijeenminutesofArrivalinPACU
Denominator:Allpa6ents,regardlessofage,undergoingsurgicalproceduresundergeneralorneuraxialanesthesiaofgreaterthanorequalto60minutesdura6on
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ExamplesofSampleSizeASC-9,ASC-10,andASC-13
Popula;onPerYear0-900YearlySampleSize 63
Popula;onPerYear≥901 YearlySampleSize 96Foreachmeasureusethedenominator/popula6ontocalculatethesamplesize.
ASC14:UnplannedAnteriorVitrectomy
Numerator:Allcataractsurgerypa6entswhohadanunplannedanteriorvitrectomy
Denominator:Allcataractsurgerypa6entsNumeratorExclusions:NoneDenominatorExclusions:None
ASC14:UnplannedAnteriorVitrectomy
Defini;ons:Admission:comple6onofregistra6onuponentryintothefacilityCataractsurgery:forpurposesofthismeasure,CPTcode66982(Cataractsurgery,complex),CPTcode66983(Cataractsurgeryw/IOL,1stage)andCPTcode66984(Cataractsurgeryw/IOL,1stage)Unplannedanteriorvitrectomy:ananteriorvitrectomythatwasnotscheduledatthe6meofthepa6ent'sadmissiontotheASC
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Thefivesurvey-basedmeasures(ASC-15a-e)arecollectedviaonesurvey{OASCAHPS}:
●ASC-15a:AboutFacili6esandStaff;●ASC-15b:Communica6onAboutProcedure;●ASC-15c:Prepara6onforDischargeandRecovery●ASC-15d:OverallRa6ngofFacility;and●ASC-15e:Recommenda6onofFacilityDatacollec6onofthesemeasureshasbeendelayed.
ASC15:Outpa6ent/AmbulatorySurgeryConsumerAssessmentofHealthcareProvidersandSystems(OASCAHPS)
• OfficialOASCAHPSwebsitehgps://oascahps.org/(Thisistheofficialwebsitefornews,trainingandinforma1onabouttheOASCAHPSsurvey.)
• Thesurveyhasthreeadministra6onmethods:–mail-only;–telephone-only;and–mixedmode(mailwithtelephonefollow-upofnon-respondents)• Toll-freenumber:1-866-590-7468forques6ons
ASC15:OASCAHPSSurveyWebsite
• ThesurveyinstrumentbecameavailableforvoluntaryuseinJanuary2016andcanbelocatedathgps://oascahps.org/Survey-Materials
• Pages12-14oftheguide“AmbulatorySurgeryCenters’Responsibili6es”
ASC15:OASCAHPSSurveyWebsite
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• ASC6,7,9&10:– Ac6veSecurityAdministratortoaccessQualityNetSecurePortal
– Recommendedtohavetwosecurityadministratorsifpossible– SignintoQualityNetsecureportalfrequently(every60days)tokeeptheaccountac6ve
KeyPointsToRemember
• ASC8(influenzavaccina6on):– NeedtoenrollwithCDCNHSN(5stepprocess),– Completesetup(3stepprocess)and
-Auser’sSecureAccessManagementServices(SAMS)accountwillbedeac6vatediftheydonotloginatallwithina12monthperiod(1year).Youwillreceiveanemailno6fica6on.
KeyPointsToRemember
• ASC9and10(colonoscopymeasures):– Thesamplesizeforeachmeasureisdeterminedbythenumberofcasesthatmeetthedenominatorcriteria.
– IfyoudonotperformendoscopyproceduresyouSTILLneedtologintowww.qualitynet.orgsecureportalandenterzeroforthenumeratoranddenominatorsinbothmeasures.
KeyPointsToRemember
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• ASC-12:(facilityseven-dayrisk-standardizedhospitalvisitrateajeroutpa6entcolonoscopy)– nodatasubmissionorrepor6ngrequiredfromASCs– forASCsperformingcolonoscopy,confiden6alreportsincludepa6entleveldataandwillbeuploadedtotheQualityNetSecurePortal
• pa6ent(medicalrecordnumber),dateofbirth,dateofservice
• typeofhospitalvisit(ED,observa6on,hospital)• admitngfacility• diagnosiscodeofhospitalvisitandhospitalID
KeyPointsToRemember
• ASC13and14(NormothermiaandUnplannedAnteriorVitrectomy)– NormothermiaOutcome-datasubmigedforaSamplingthatmeetthedenominatorcriteria.
– UnplannedAnteriorVitrectomy-datasubmigedforAllPa%entsthatmeetthedenominatorcriteria.
– IfyoudonotperformtheseproceduresyouSTILLneedtologintowww.qualitynet.orgsecureportalandenterzeroforthenumeratoranddenominatorinbothmeasures.
KeyPointsToRemember
• EachfacilityshouldhaveatleasttwopeoplesignedupfortheQualityNetemailno6fica6ons– Gotowww.qualitynet.org;clickonambulatorysurgerycenterandclickonemailno6fica6on
KeyPointsToRemember
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2018MedicareHospitalOutpa6entProspec6vePaymentSystem(OPPS)/ASCPayment
FinalRule
• ReleasedonNovember1,2017• hgps://s3.amazonaws.com/public-inspec6on.federalregister.gov/2017-23935.pdf
• ASCQualityRepor6ngProgrambeginsonpage922:Sec6onXIV.RequirementsfortheAmbulatorySurgicalCenterQualityRepor1ng(ASCQR)Program
2018MedicareHospitalOutpa6entProspec6vePaymentSystem(OPPS)/ASCPayment
FinalRule• MaintainedpreviousmeasuresASC1-4;8-14• RemovedthreemeasuresfromtheASCQRProgrammeasureset:-ASC–5:Prophylac6cIntravenous(IV)An6bio6cTiming,- ASC–6:SafeSurgeryChecklistUseand,- ASC–7:AmbulatorySurgicalCenterFacilityVolumeDataonSelectedAmbulatorySurgicalCenterSurgicalProcedures.
BeginningwiththeCY2019paymentdetermina6on(datacollec6on2017)
• Delayedimplementa6onof(ASC15a-e):OASCAHPSSurveymeasuresbeginningwiththeCY2020paymentdetermina6on(datacollec6on2018)
2018MedicareHospitalOutpa6entProspec6vePaymentSystem(OPPS)/ASCPayment
FinalRule• DidnotadoptthenewmeasurefortheCY2021paymentdetermina6on
(datacollec6on2019)andsubsequentyears:- ASC-16:ToxicAnteriorSegmentSyndrome(TASS)
• AdoptedtwonewmeasuresfortheCY2022paymentdetermina6onandsubsequentyears:- ASC-17:HospitalVisitajerOrthopedicAmbulatorySurgery
Procedures- ASC-18:HospitalVisitajerUrologyAmbulatorySurgeryProcedures
• ExpansionoftheCMSonlinetooltoallowforbatchsubmissionbeginningwithdatasubmigedduringCY2018fortheCY2020paymentdetermina6onandsubsequentyears
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ASC17:HospitalVisitsajerOrthopedicAmbulatorySurgicalCenterProcedures
• DataispulledbyCMSfromtheMedicareFeeforServiceadministra1veclaimsbilledbythecenter.
• Nodatasubmissionorrepor6ngrequiredfromtheASC
• Datacollec6onperiodfortheCY2022paymentdetermina6onwouldbeCY2019to2020(twocalendaryears).
• Themeasureoutcomeisall-cause,unplannedhospitalvisits(EmergencyDepartmentVisit,Observa6onStays,UnplannedInpa6entAdmission)withinsevendaysofanorthopedicprocedureperformedatanASC.
• ClaimsDetailReports(CDR)willbeuploadedtoQualityNetsecureportalfor
facilityreview.
ASC18:HospitalVisitsajerUrologyAmbulatorySurgicalCenterProcedures
• DataispulledbyCMSfromtheMedicareFeeforServiceadministra1veclaimsbilledbythecenter.
• Nodatasubmissionorrepor6ngrequiredfromtheASC
• Datacollec6onperiodfortheCY2022paymentdetermina6onwouldbeCY2019to2020(twocalendaryears).
• Themeasureoutcomeisall-cause,unplannedhospitalvisits(EmergencyDepartmentVisit,Observa6onStays,UnplannedInpa6entAdmission)withinsevendaysofanurologyprocedureperformedatanASC.
• ClaimsDetailReports(CDR)willbeuploadedtoQualityNetsecureportalfor
facilityreview.
Ques6ons?
Ø ForASCQualityRepor6ngProgramQues6ons:ContactHealthServicesAdvisoryGroup(HSAG)(formerlyFMQAI)athgps://cms-ocsq.custhelp.com/orviaphone(866)800-8756MondaythroughFriday,7a.m.to6p.m.EasternTime
Ø ForCentersforDiseaseControlandPreven6on(CDC)Na6onalHealthcareSafetyNetwork(NHSN)InfluenzaVaccina6onQues6ons:[email protected]“HPSFluSummary-ASC”inthesubjectline
ForassistancewithSAMS,contacttheSAMSHelpDesk@[email protected]
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ContactInforma6on
GinaThroneberry,RN,MBA,CASC,CNORDirectorofEduca6onandClinicalAffairs
AmbulatorySurgeryCenterAssocia6on(ASCA)[email protected]
Join The Community! • For the resources referenced today and SO
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www.progressivesurgicalsolutions.com/esupport • Email us at [email protected] • Or call us! (855) 777-4272
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