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CMS Quality Reporting for ASCs

CMS Quality Reporting for ASCs. Gina Throneberry, RN, MBA, CASC, CNOR Director of Education and Clinical Affairs Ambulatory Surgery Center Association (ASCA). Learning Objectives. Participants will:

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CMS Quality Reporting for ASCs

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  1. CMS Quality Reporting for ASCs Gina Throneberry, RN, MBA, CASC, CNOR Director of Education and Clinical Affairs Ambulatory Surgery Center Association (ASCA)

  2. Learning Objectives • Participants will: • Identify quality reporting by Centers for Medicare & Medicaid Services (CMS) for Ambulatory Surgery Centers (ASCs) • Understand the history of quality measure development • Collect and report the data for the required quality measures

  3. General FAQs about the CMS ASC Quality Reporting Program • I would like clarification on the definition of an Ambulatory Surgical Center (ASC) as it relates to the requirements for the ASC Quality Reporting Program. My understanding is that only free-standing ASCs that are billing with their own CCN would be required to submit under that program. Is this correct? You are correct. ASCs have their own ASC numbers - an alphanumeric code where the third digit is the letter "C" - and bill using their own system. An ASC that is part of a hospital's regional outpatient facility that is billing under the hospital's CCN would not be included. The ambulatory surgery cases billed under the hospital's CCN would be eligible for inclusion in the relevant measures in the Hospital Outpatient Quality Reporting (OQR) Program. * *Per www.qualitynet.org

  4. General FAQs about the CMS ASC Quality Reporting Program • What is a CCN, and where can I locate it? A Center for Medicare and Medicaid Services (CMS) Certification Number, or CCN, is established by CMS for each facility and designates the facility as a CMS-certified, free standing ASC. Your billing department should serve as a good resource for locating this number. An ASC CCN is an alphanumeric 10 digit number - the first two digits represent the state's number, and the following letter is a "C." For example, an ASC in Florida would have a CCN that looks like "10C000xxxx.“ * *Per www.qualitynet.org

  5. ASCQR Program Rule History

  6. 2012 HOPD/ASC Final Rule (CMS 1525FC) Quality Reporting Program • On November 1, 2011, Medicare released the calendar year (CY) 2012 Medicare Hospital Outpatient Prospective Payment System (OPPS)/ ASC Payment final rule (1552 pages) • The ASC Quality Reporting Program was implemented beginning with the CY 2014 payment determination, data collection began in CY 2012 for some of the measures • Pay for Reporting; Not Pay for Performance at this time • ASCs that fail to successfully report will face a 2% facility fee reduction in future year’s rates.

  7. ASCQR Program Measures Summary

  8. ASC Quality Collaboration, Inc.Measures Implementation Guidewww.ascquality.org

  9. CMS Ambulatory Surgical Center Quality Reporting Program • CMS ASC Quality Reporting Program Quality Measures Specifications Manual • To date- 6 versions (April 2012-December 2013) • Latest version- 3.0a (December 2013) • Located @ www.qualitynet.org under ASC tab • Included in this manual: • Measure specifications • Data collection and submission • Quality Data Codes (QDCs)

  10. Measures for ASCs ASC Program Measurement Set for the CY 2014 and 2015 PaymentDetermination • 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

  11. How Will the Data be Reported? • 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 Quality Net (www.qualitynet.org) • Safe Surgery Check List Use • ASC Volume of Selected Procedures for all-patients • Web Based Reporting Via Center for Disease Control’s (CDC) National Health Care Safety Network (NHSN) (www.cdc.gov/nhsn/index.html) • Influenza Vaccination Coverage Among Health Care Personnel

  12. General FAQs about the CMS ASC Quality Reporting Program • Do we need to include Pre-Admission Testing (PAT) visits conducted in an ASC for the ASCQR Program? A visit for PAT is not considered an ASC admission for purposes of the ASCQR Program.* • Can we submit claims to correct G codes? Do not re-submit a claim only for the purpose of correcting or adding G-codes. Resubmission of claims should occur only to collect the payment from the original date of service. * *Per www.qualitynet.org

  13. General FAQs about the CMS ASC Quality Reporting Program • If a patient is admitted to the ASC, but the case is cancelled before any procedure is performed, does quality measure data need to be reported for this case? If the ASC submits a claim for Medicare reimbursement for this case, then the appropriate QDCs should be reported as this claim will be included in the completeness of reporting calculation.* *Per www.qualitynet.org

  14. Inpatient/Long Term Care Hospital Prospective Payment System (IPPS) Final Rule • Released August 2012 • The final rule can be accessed at (https://s3.amazonaws.com/public-inspection.federalregister.gov/2012-19079.pdf) • This is the vehicle for rulemaking on the specifics of the ASC quality reporting program: • Data completeness and validation • Reconsideration and appeals process • Limited details for public reporting of data

  15. Additional Quality Reporting Info from the IPPS* Final Rule (July 2012) • ASC information begins on page 1534; Section E. Proposed Quality Reporting Requirements for Ambulatory Surgical Centers (ASCs) • Participation in the CMS ASC Quality Reporting Program. Page 1540 • Publicly reporting quality data. Page 1541. *Inpatient Prospective Payment Systems

  16. Additional Quality Reporting Info from the IPPS* Final Rule (July 2012) • The completeness threshold is set at 50%. Page 1548 • ASCs will be considered successful reporters and get their full payment if 50% of the relevant claims contain the quality data codes (2012 and 2013).   • There is a process for an extension in extraordinary circumstances. Page 1554. • The reconsideration and appeals process is based on the one the hospital uses now. Page 1558. *Inpatient Prospective Payment Systems

  17. Participation and Non Participation • Once an ASC submits any quality measure data, the center would be considered participating • To receive the full annual payment update (APU), an ASC must meet all program requirements: • submits quality measure data (i.e., Quality Data Codes [QDCs]) on the CMS Form 1500 • submits web-based measure data • 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. • For ASCs participating in the program, quality measure data submitted could be made publicly available.

  18. Participation and NonParticipation • 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.

  19. Extraordinary Circumstances Extension/ Waiver Process • 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

  20. Reconsideration 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

  21. Measures for ASCs ASC Program Measurement Set for the CY 2015 PaymentDetermination • 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} *New measures for CY 2015 payment determination; Data collection began CY 2012

  22. Measure Details 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: • prior to administering anesthesia, • prior to incision, and • prior to the patient leaving the operating room • Applies to all ASCs

  23. Measure Details Safe Surgery Checklist Use • 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 January1 through August 15, 2015.

  24. Measure Details Safe Surgery Checklist Resources • World Health Organization (WHO) • http://www.who.int/patientsafety/safesurgery/ss_checklist/en/ • SafeSurg.org: • For a modifiable template: http://www.safesurg.org/template-checklist.html • For examples, including for endoscopy centers: http://www.safesurg.org/modified-checklists.html • AORN (combines WHO checklist and JC universal protocol) • http://www.aorn.org/PracticeResources/ToolKits/CorrectSiteSurgeryToolKit/Comprehensivechecklist/

  25. Measure Details 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 yearon the QualityNet web site (www.qualitynet.org) between January 1 thru August 15, 2015

  26. Measure Details • The specifications manual version 3.0a released in December 2013 contains a new table of HCPCS or CPT codes. • This revision was based on claims data from 2012, the top 100 procedures (based on volume) were determined, and the corresponding codes were used to update the table within the measure.

  27. How Will the Data be Reported? • 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 Quality Net (www.qualitynet.org) • Safe Surgery Check List Use • ASC Volume of Selected Procedures for all-patients • Web Based Reporting Via Center for Disease Control’s (CDC) National Health Care Safety Network (NHSN) (www.cdc.gov/nhsn/index.html) • Influenza Vaccination Coverage Among Health Care Personnel

  28. How Will the Data be Reported? • Web Based Reporting via Quality Net (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

  29. Requirements for QualityNet Account and Administrator • A QualityNet account is required to submit quality data to the QualityNet Web site • ASCs will need to identify and register a QualityNet administrator who follows the registration process located on the QualityNet Web site • Allow 6 weeks for the security administrator process to be completed • QualityNet accounts are automatically deactivated after a 120-day period of inactivity in accordance with CMS security policy.

  30. QualityNet Home Pagewww.qualitynet.org

  31. QualityNet Home Page ASC Registration is located in a blue box on the left hand side of the home page

  32. QualityNet ASC Registration

  33. Additional Requirements for QualityNet Account and Administrator • As of May 31, 2013, the Centers for Medicare & Medicaid Services (CMS) is now requiring QualityNetusers for the ASC Quality Reporting Program complete an additional user enrollment process to ensure access to the Secure QualityNet Portal. • After receiving a user ID and password, the security administrator will now be required to download the Symantec VIP Access application (Symantec VIP multifactor credential application). • When logging in to the portal for the first time, security administrators will be guided through a six‐step New User Enrollment Process that includes personal identity verification conducted by Experian, an external service enlisted by CMS.

  34. Secure QualityNet Portal Log In QualityNet Portal Log-in

  35. QualityNet Portal Registration Start/Complete New User Enrollment Quick Link to VIP Access App

  36. QualityNet Secure Portal

  37. Measures for ASCs ASC Program Measurement Set for the CY 2016PaymentDetermination • 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

  38. Measure Details Influenza Vaccination Coverage among Healthcare Personnel (HCP) • Intent: assess the percentage of HCP immunized for influenza during the flu season • Center for Disease Control (CDC) in the process of revising measure specifications for ASCs • 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

  39. Influenza Vaccination Coverage Among Healthcare Personnel (HCP) • Measurement 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 • Deadline for ASC submission will be finalized with the final rule for CY 2015

  40. Enrollment Steps • 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

  41. SAMS • Users must fax or mail notarized proof of identity to CDC. • This is not a background check – this information will only be used to verify your identity and will not be shared outside of NHSN • 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)

  42. Reporting to NHSN • Report to CDC’s National Healthcare Safety Network (NHSN): www.cdc.gov/nhsn/index.htmlOctober 1, 2014 through March 31, 2015 • Enter data for all numerator and denominator categories

  43. Influenza Vaccination Summary

  44. Denominator Categories • Employee HCP • Non-Employee HCP: Licensed independent practitioners (physicians, advance practice nurses, and physician assistants) • Non-Employee HCP: Adult students/trainees and volunteers

  45. Numerator Categories • Influenza vaccinations • Received at this healthcare facility • Received elsewhere • Medical contraindications • Declinations • Unknown status

  46. Notes on Reporting – Example • 10 + 20 + 15 + 5 + 5 = 55 • 70 + 10 + 10 + 5 + 5 = 100 • 20 + 2 + 1 + 1 + 1 = 25

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