1/17/18. CMS Quality Measure Repor6ng Update. ASCQR Program Measures Summary

Transcription

1 Keeping you in the know in the ASC industry CMS Quality Repor6ng Update Gina Throneberry, RN, MBA, CASC, CNOR Director of Educa6on and Clinical Affairs Ambulatory Surgery Center Associa6on (ASCA) ASCQR Program s Summary Number Title Type of Data Collection Data Reporting Payment Dates Dates Determination Year Applies To ASC-1 Patient Burn Claims-Based December December CY 2019 Medicare Part B fee for service patients December December CY 2020 ASC-2 Patient Fall Claims-Based December December CY 2019 Medicare Part B fee for service patients December December CY 2020 ASC-3 Wrong Site, Wrong Side, Claims-Based December December CY 2019 Medicare Part B fee Wrong Patient, Wrong for service patients Procedure,Wrong Implant December December CY 2020 ASC-4 Hospital Transfer/ Claims-Based December December CY 2019 Medicare Part B fee Admission for service patients December December CY 2020 ASC-5 Prophylactic Intravenous Claims-Based December December removed Medicare Part B fee (IV) Antibiotic Timing for CY 2019 for service patients No reporting in

2 ASCQR Program s Summary Number Title Type of Data Collection Data Reporting Payment Dates Dates Determination Applies Year To ASC-6 Safe Surgery Checklist Web-Based via Removed All patients Use QualityNet secure portal December May 15, 2018 No reporting in for CY ASC-7 ASC Facility Volume Web-Based via Removed All patients Data on Selected ASC Surgical Procedures QualityNet secure portal December May 15, 2018 No reporting in for CY ASC-8 Influenza Vaccination Web-Based October 1, 2017 Through May 15, CY 2019 Health Care Coverage among via National March 2018 Personnel Healthcare Personnel Healthcare Safety Network (NHSN) October 1, 2018 Through May 15, CY 2020 Health Care March 31, Personnel ASCQR Program s Summary Number Title Type of Data Collection Data Reporting Payment Dates Dates Determination Applies Year To ASC-9 Endoscopy/Polyp Surveillance: Web-Based via May 15, 2018 CY 2019 Sampling Appropriate Follow-Up Interval for QualityNet December Normal Colonoscopy in Average secure portal Risk Patients May 15, 2019 CY 2020 December ASC-10 Endoscopy/Polyp Surveillance: Web-Based via May 15, 2018 CY 2019 Sampling Colonoscopy Interval for Patients QualityNet December with a History of Adenomatous secure portal Polyps Avoidance of Inappropriate Use May 15, 2019 CY 2020 December ASC-11 Cataracts- Improvement in Web-Based via May 15, 2018 CY 2019 Sampling Voluntary Patient s Visual Function within 90 QualityNet December days following Cataract Surgery secure portal May 15, 2019 CY 2020 December ASC-12 Facility Seven-Day Risk Administrative Paid Medicare Fee Paid Medicare Fee for CY 2019 Paid Standardized Hospital Visit Rate Claims-Based for Service Claims Service Administrative Medicare after Outpatient Colonoscopy Claims Fee for December Preview Reports were Service and subsequent available for review on Claims years QualityNet ASCQR Program s Summary Number Title Type of Data Collection Dates Data Reporting Dates Payment Determination Year Applies To ASC-13 Normothermia Web-based via May CY 2020 Sampling QualityNet December 31, 15, 2019 secure portal 2018 ASC-14 Unplanned Anterior Web-based via May CY 2020 All Patients Vitrectomy QualityNet secure portal December 31, , 2019 Meeting Criteria ASC-15 Outpatient and Survey Quarterly by CY 2020 All Patients with (15 a-e) Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS Administered by an approved vendor December 31, 2018 Delayed CMS approved vendor Delayed Exclusions 300 Completed Surveys via Approved Vendor 2

3 ASCQR Program s Summary Number Title Type of Data Collection Data Reporting Payment Dates Dates Determination Year Applies To ASC-16 Toxic Anterior Web-based via May CY 2021 All Patients Not Segment Syndrome Finalized (TASS) QualityNet secure portal December 31, , 2020 Meeting Criteria ASC-17 Hospital Visit After Administrative Paid Medicare Fee Paid Medicare CY 2022 Paid Medicare Final Orthopedic Ambulatory Surgery Procedures Claims Based for Service Claims December 31, 2020 Fee for Service Administrative Claims Fee for Service Claims ASC-18 Hospital Visit After Administrative Paid Medicare Fee Paid Medicare CY 2022 Paid Medicare Final Urology Ambulatory Surgery Procedures Claims Based for Service Claims December 31, 2020 Fee for Service Administrative Claims Fee for Service Claims CMS Ambulatory Surgical Center Quality Repor6ng Program CMS ASC Quality Repor6ng Program Quality s Specifica6ons Manual Verify you have the latest versions 7.0a 1Q18-4Q18 (released 12/8/17) 6.0a 1Q17-4Q17 under ASC tab Included in this manual: specifica6ons Data collec6on and submission Quality Data Codes (QDCs) ASC Quality Repor6ng Program s ASC-1: Pa6ent Burn ASC-2: Pa6ent Fall ASC-3: Wrong Site, Wrong Side, Wrong Pa6ent, Wrong Procedure, Wrong Implant ASC-4: Hospital Transfer/Admission ASC-5: Prophylac6c Intravenous (IV) An6bio6c Timing (no repor6ng in 2018) Medicare Part B Fee for Service Pa1ents Claims Based Repor6ng Quality Data Codes (QDCs) 3

4 ASC Quality Repor6ng Program s ASC-6: Safe Surgery Checklist Use (no repor6ng in 2018) ASC-7: ASC Facility Volume Data on Selected ASC Surgical Procedures (no repor6ng in 2018) ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Pa6ents ASC-10: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Pa6ents with a History of Adenomatous Polyps-Avoidance of Inappropriate Use Web Based Repor;ng via QualityNet Secure Portal ( Data collec%on: January 1 through December Data repor%ng: January 1 through May 15, 2018 Data collec%on: January 1 through December Data repor%ng: January 1 through May 15, 2019 ASC Quality Repor6ng Program s ASC- 8: Influenza Vaccina6on Coverage among Healthcare Personnel Web Based Repor;ng Via Centers for Disease Control and Preven;on (CDC) Na;onal Health Care Safety Network (NHSN) ( Data collec%on begins with immuniza6ons for the flu season October 1, 2017 through March Deadline for data repor%ng for the flu season is May 15, ASC Quality Repor6ng Program s ASC- 8: Influenza Vaccina6on Coverage among Healthcare Personnel In December 2017 NHSN users needed to accept an updated NHSN Agreement to Par6cipate and Consent, even if you had submiged one previously. This new form should have been submiged electronically through NHSN. Your facility s primary contact was required to accept the new form by April 14, 2018 or you would not be able to submit data in NHSN for ASC-8. NHSN func6onality will be disabled un6l the consent form is accepted by your facility s primary contact. 4

5 ASC Quality Repor6ng Program s ASC-12: Facility Seven-Day Risk-Standardized Hospital Visit Rate ajer Outpa6ent Colonoscopy Data is pulled by CMS from the Medicare Fee for Service administra1ve claims that were billed by the center star6ng December 31, 2016 and subsequent years. No data submission or repor6ng required from the ASC Colonoscopy Claims Detail Reports (CDR) will be periodically uploaded to the QualityNet secure portal throughout the year. ASC Quality Repor6ng Program s ASC 13 Normothermia Outcome Data submiged for a Sampling that meet the denominator criteria. ASC 14 Unplanned Anterior Vitrectomy Data submiged for All Pa%ents that meet the denominator criteria. Web Based Repor;ng via QualityNet Secure Portal ( Data collec%on: January 1 through December Data repor%ng: January 1 through May 15, 2019 ASC 13: Normothermia Outcome Numerator: Surgery pa6ents with a body temperature equal to or greater than 96.8 Fahrenheit/36 Celsius recorded within fijeen minutes of Arrival in PACU Denominator: All pa6ents, regardless of age, undergoing surgical procedures under general or neuraxial anesthesia of greater than or equal to 60 minutes dura6on 5

6 Examples of Sample Size ASC-9, ASC-10, and ASC-13 Popula;on Per Year Yearly Sample Size 63 Popula;on Per Year 901 Yearly Sample Size 96 For each measure use the denominator/popula6on to calculate the sample size. ASC 14: Unplanned Anterior Vitrectomy Numerator: All cataract surgery pa6ents who had an unplanned anterior vitrectomy Denominator: All cataract surgery pa6ents Numerator Exclusions: None Denominator Exclusions: None ASC 14: Unplanned Anterior Vitrectomy Defini;ons: Admission: comple6on of registra6on upon entry into the facility Cataract surgery: for purposes of this measure, CPT code (Cataract surgery, complex), CPT code (Cataract surgery w/iol, 1 stage) and CPT code (Cataract surgery w/iol, 1 stage) Unplanned anterior vitrectomy: an anterior vitrectomy that was not scheduled at the 6me of the pa6ent's admission to the ASC 6

7 ASC 15: Outpa6ent/Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) The five survey-based measures (ASC-15a-e) are collected via one survey {OAS CAHPS}: ASC-15a: About Facili6es and Staff; ASC-15b: Communica6on About Procedure; ASC-15c: Prepara6on for Discharge and Recovery ASC-15d: Overall Ra6ng of Facility; and ASC-15e: Recommenda6on of Facility Data collec6on of these measures has been delayed. ASC 15: OAS CAHPS Survey Website Official OAS CAHPS website hgps://oascahps.org/ (This is the official website for news, training and informa1on about the OAS CAHPS survey.) The survey has three administra6on methods: mail-only; telephone-only; and mixed mode (mail with telephone follow-up of nonrespondents) Toll-free number: for ques6ons ASC 15: OAS CAHPS Survey Website The survey instrument became available for voluntary use in January 2016 and can be located at hgps://oascahps.org/survey-materials Pages of the guide Ambulatory Surgery Centers Responsibili6es 7

8 Key Points To Remember ASC 6, 7, 9 & 10: Ac6ve Security Administrator to access QualityNet Secure Portal Recommended to have two security administrators if possible Sign in to QualityNet secure portal frequently (every 60 days) to keep the account ac6ve Key Points To Remember ASC 8 (influenza vaccina6on): Need to enroll with CDC NHSN (5 step process), Complete set up (3 step process) and - A user s Secure Access Management Services (SAMS) account will be deac6vated if they do not log in at all within a 12 month period (1 year). You will receive an no6fica6on. Key Points To Remember ASC 9 and 10 (colonoscopy measures): The sample size for each measure is determined by the number of cases that meet the denominator criteria. If you do not perform endoscopy procedures you STILL need to log into secure portal and enter zero for the numerator and denominators in both measures. 8

9 Key Points To Remember ASC-12: (facility seven-day risk-standardized hospital visit rate ajer outpa6ent colonoscopy) no data submission or repor6ng required from ASCs for ASCs performing colonoscopy, confiden6al reports include pa6ent level data and will be uploaded to the QualityNet Secure Portal pa6ent (medical record number), date of birth, date of service type of hospital visit (ED, observa6on, hospital) admitng facility diagnosis code of hospital visit and hospital ID Key Points To Remember ASC 13 and 14 (Normothermia and Unplanned Anterior Vitrectomy) Normothermia Outcome- data submiged for a Sampling that meet the denominator criteria. Unplanned Anterior Vitrectomy- data submiged for All Pa%ents that meet the denominator criteria. If you do not perform these procedures you STILL need to log into secure portal and enter zero for the numerator and denominator in both measures. Key Points To Remember Each facility should have at least two people signed up for the QualityNet no6fica6ons Go to click on ambulatory surgery center and click on no6fica6on 9

10 2018 Medicare Hospital Outpa6ent Prospec6ve Payment System (OPPS)/ASC Payment Final Rule Released on November 1, 2017 hgps://s3.amazonaws.com/publicinspec6on.federalregister.gov/ pdf ASC Quality Repor6ng Program begins on page 922: Sec6on XIV. Requirements for the Ambulatory Surgical Center Quality Repor1ng (ASCQR) Program 2018 Medicare Hospital Outpa6ent Prospec6ve Payment System (OPPS)/ASC Payment Final Rule Maintained previous measures ASC 1-4; 8-14 Removed three measures from the ASCQR Program measure set: - ASC 5: Prophylac6c Intravenous (IV) An6bio6c Timing, - ASC 6: Safe Surgery Checklist Use and, - ASC 7: Ambulatory Surgical Center Facility Volume Data on Selected Ambulatory Surgical Center Surgical Procedures. Beginning with the CY 2019 payment determina6on (data collec6on 2017) Delayed implementa6on of (ASC 15a-e): OAS CAHPS Survey measures beginning with the CY 2020 payment determina6on (data collec6on 2018) 2018 Medicare Hospital Outpa6ent Prospec6ve Payment System (OPPS)/ASC Payment Final Rule Did not adopt the new measure for the CY 2021 payment determina6on (data collec6on 2019) and subsequent years: - ASC-16: Toxic Anterior Segment Syndrome (TASS) Adopted two new measures for the CY 2022 payment determina6on and subsequent years: - ASC-17: Hospital Visit ajer Orthopedic Ambulatory Surgery Procedures - ASC -18: Hospital Visit ajer Urology Ambulatory Surgery Procedures Expansion of the CMS online tool to allow for batch submission beginning with data submiged during CY 2018 for the CY 2020 payment determina6on and subsequent years 10

11 ASC 17: Hospital Visits ajer Orthopedic Ambulatory Surgical Center Procedures Data is pulled by CMS from the Medicare Fee for Service administra1ve claims billed by the center. No data submission or repor6ng required from the ASC Data collec6on period for the CY 2022 payment determina6on would be CY 2019 to 2020 (two calendar years). The measure outcome is all-cause, unplanned hospital visits (Emergency Department Visit, Observa6on Stays, Unplanned Inpa6ent Admission) within seven days of an orthopedic procedure performed at an ASC. Claims Detail Reports (CDR) will be uploaded to QualityNet secure portal for facility review. ASC 18: Hospital Visits ajer Urology Ambulatory Surgical Center Procedures Data is pulled by CMS from the Medicare Fee for Service administra1ve claims billed by the center. No data submission or repor6ng required from the ASC Data collec6on period for the CY 2022 payment determina6on would be CY 2019 to 2020 (two calendar years). The measure outcome is all-cause, unplanned hospital visits (Emergency Department Visit, Observa6on Stays, Unplanned Inpa6ent Admission) within seven days of an urology procedure performed at an ASC. Claims Detail Reports (CDR) will be uploaded to QualityNet secure portal for facility review. Ques6ons? Ø For ASC Quality Repor6ng Program Ques6ons: Contact Health Services Advisory Group (HSAG) (formerly FMQAI) at hgps://cms-ocsq.custhelp.com/ or via phone (866) Monday through Friday, 7 a.m. to 6 p.m. Eastern Time Ø For Centers for Disease Control and Preven6on (CDC) Na6onal Healthcare Safety Network (NHSN) Influenza Vaccina6on Ques6ons: Contact NHSN@cdc.gov and include HPS Flu Summary-ASC in the subject line For assistance with SAMS, contact the SAMS Help or samshelp@cdc.gov 11

12 Contact Informa6on Gina Throneberry, RN, MBA, CASC, CNOR Director of Educa6on and Clinical Affairs Ambulatory Surgery Center Associa6on (ASCA) Join The Community! For the resources referenced today and SO MUCH MORE Request your free web demo today us at Or call us! (855) Available on esupport Compliance/Quality Reporting/Overview 12

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