Preparing GI ASCs for October 2012 Anita J. Bhatia, PHD, MPH, Centers for Medicare and Medicaid Services Lawrence B. Cohen, MD, FACG, AGAF, FASGE, New York Gastroenterology Associates Lawrence R. Kosinski, MD, MBA, AGAF, Illinois Gastroenterology Group James Leavitt, MD, President & CEO, Gastro Health
Anita J. Bhatia, PhD, MPH, is the Centers for Medicare and Medicaid id Services (CMS) Program Lead for the recently implemented Ambulatory Surgical Center Quality Reporting Program. Dr. Bhatia s doctorate and Masters of Public Health degree are from the University of Massachusetts at Amherst and the Johns Hopkins School of Public Health, respectively. Over the past 20 years, her work experience includes 12 years at CMS in quality improvement programs, public health epidemiologist, research scientist, and statistical consultant. Lawrence B. Cohen, MD, FACG, AGAF, FASGE, is the chair of the ACG Practice Management Committee, Clinical Professor of Medicine at The Mount Sinai School of Medicine in New York, NY and the managing partner of New York Gastroenterology Associates. He graduated from Hahnemann Medical College with highest honors and completed his medical residency and fellowship training at The Mount Sinai Hospital. Dr. Cohen s primary research focus is gastrointestinal endoscopy and he lectures throughout the world on subjects ranging from colonoscopy and colorectal cancer screening to endoscopic sedation. He has authored more than 150 book chapters, articles and abstracts and serves on the editorial board or as a scientific reviewer for seven journals. His contributions to gastroenterology and expertise in the field have been recognized by his peers who selected him to be listed in Best Doctors in America, America s Best Gastroenterologists and Top Doctors in New York. Lawrence R. Kosinski, MD, MBA, AGAF, FACG, is the chair of the AGA Institute Practice Management and Economics Committee and a managing partner at Illinois Gastroenterology Group, Elgin, IL. A practicing gastroenterologist, g Dr. Kosinski is a board member at Sherman Hospital and on staff at St. Joseph Hospital. He received his medical degree from Loyola Stritch School of Medicine and completed a residency in internal medicine and fellowship in gastroenterology at Loyola University. Dr. Kosinski earned his MBA from the Northwestern University Kellogg School of Business. James S. Leavitt, MD, has been in practice since 1980 and is the President/CEO of Gastro Health, one of the largest single specialty, private practice Gastroenterology groups in Florida with almost 40 physicians. Dr. Leavitt is a graduate of Dartmouth College, Magna Cum Laude, and the State University of New York Downstate Medical School. He completed his medical internship and residency at Jackson Memorial Hospital in Miami as well as his Gastroenterology fellowship. Dr. Leavitt is board certified in Gastroenterology and Internal Medicine, and has been named one of the top 28 Gastroenterologists in America by Becker's ASC Review and has been named by U.S. News as one of the nation s Top Doctors. Dr. Leavitt currently serves on the ASGE Practice Management Committee.
Overview of ASC Quality Reporting Program How systems can work together Frequently asked questions Q&A
Describe what is the Ambulatory Surgical Center Quality Reporting Program Understand the current program timeline Define the quality measures Understand what data to report and how Know where to obtain assistance Answer some frequently asked questions
Statutory origins in the Tax Relief and Health Care Act (TRCHA) of 2006 CMS finalized the implementation of a ASC Quality Reporting Program in the CY 2012 Medicare Hospital Outpatient Prospective Payment System (OPPS) final rule and finalized additional requirements in the FY 2013 IPPS/LTCH final rule Medicare certified ASCs are required to report data on the quality of care delivered in these facilities ASCs that fail to successfully meet program requirements may incur a 2% reduction in their annual payment update for a given payment year beginning i with CY 2014 Pay for Reporting; Not Pay for Performance
QUALITY REPORTING TIMELINE 2012 April 1, 2012: Quality Data Codes available for trial reporting October 1: Quality Data Code reporting begins: 50% of Medicare claims must contain required codes Oct 1 through Dec 31, 2012 Include Quality Data Codes only on claims where Medicare is the primary payer January 1: Include Quality Data Codes on claims where Medicare is either the primary or secondary payer Jul 1- Aug 15: Report 2012 use of safe surgery checklist and total 2012 surgical volume on the QualityNet t website 2013 2014 For all patients, use a safe surgery checklist at any time during the year and track surgical volume from Jan 1 to Dec 31 to report in July 1, through Aug 15, 2013 Register for a Security Administrator for access to MY QualityNet at http://www.quailtynet.org Influenza Vaccination Coverage among Health Care Professionals measure added to required reporting ASC Quality Reporting Program continues 2015
ASC Quality Reporting Measure Initial Reporting Period Initial Payments Affected 1. Patient Burn Begins Oct 1, 2012 2014 2. Patient Fall Begins Oct 1, 2012 2014 3. Wrong Site, Side, Patient, Begins Oct 1, 2012 2014 Procedure, Implant 4. Hospital Admission/Transfer Begins Oct 1, 2012 2014 5. Prophylactic IV Antibiotic Timing Begins Oct 1, 2012 2014 6. Safe Surgery Check List Use July 1 thru Aug 15, 2013 2015 (for 1/1/12-12/31/12) 7. Volume of Selected Procedures July 1 thru Aug 15, 2013 (for 1/1/12-12/31/12) 12/31/12) 2015 8.Influenza Vaccination Coverage Among Health Care Workers Oct 1, 2014 thru Mar 31, 2015 2016
Claims-based Reporting Quality Data Codes ASC-1 Patient Burn ASC-2 Patient Fall ASC-3 Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant ASC-4 Hospital Admission/Transfer ASC-5 Prophylactic IV Antibiotic Timing Web-based Reporting ASC 6SafeSurgeryCheckListUse ASC-6 Safe Surgery Check List Use ASC-7 ASC Facility Volume Data on Selected ASC Surgical Procedures (all payer) National Health Care Safety Network (NHSN) National Health Care Safety Network (NHSN) ASC-8 Influenza Vaccination Coverage Among Health Care Workers
CPT Category II codes or Level II G-codes Codes for presence or absence of event Report 2 or 5 QDC per claim Completeness of Reporting Threshold of 50% based on claim counts Medicare as primary payer for Oct to Dec 2012 services Medicare as primary or secondary payer for Jan 1, 2013 services forward
530.81 10 31 12 10 31 12 43250 1 895.50 10 31 12 10 31 12 G8909 1 0 10 31 12 10 31 12 G8911 1 0 10 31 12 10 31 12 G8913 1 0 10 31 12 10 31 12 G8914 1 0 10 31 12 10 31 12 G8918 1 0
550.92 10 31 12 10 31 12 49521 1 1450.50 10 31 12 10 31 12 G8907 1 0 10 31 12 10 31 12 G8916 1 0
QualityNet Web-site http://www.qualitynet.org Question & Answer Tool Link on QualityNet site Directly by https://cms-ocsq.custhelp.com/ Listserv https://www.qualitynet.org/dcs/contentserver?pagename=qnetpublic/lis tserve/register CMS Web site ASC Center http://www.cms.gov/center/provider-type/ambulatory- Surgical-Centers-ASC-Center.html Quality Reporting Initiatives section Direct Telephone (toll free) 1-866-800-8756, Monday to Friday 7am to 6 pm ET Email http://www.hospitaloqr@fmqai.com
QDC is needed on Medicare claims 50% threshold required to avoid penalty Even if no quality issue occurred A default code can be created in the PM System Coding by exception is most reasonable The reporting should be seamlessly integrated into the workflow Clinical reporting in the ASC EMR should automatically trigger the appropriate G Code in the Practice Management System
Documentation of quality metrics should ideally be seamlessly integrated into the process of care EMRs usually need to be customized in order to accomplish this.
Ultimately, this is encounter data and has to be reported with our claims Ideally this should be a silent process to the physician
Each Handoff is a Potential Point of Failure The Challenge: In an electronic health record environment there are three to four handoffs as one component transfers data to the next. Awareness of each is critical and creating an awareness of where your vendors stand in the development and testing process is a critical management requirement. Typical Handoffs: o Each measure MUST be clearly documented in the patient medical record. o The EHR component must handoff ( )) the appropriate p G-code to the billing component. o Some practices may deploy separate EHR and PMS requiring an additional handoff ( ). o Typically the PMS will build a charge batch and handoff ( ) the data to a Clearing House. o The Clearing House will then handoff ( ) the batch to a Medicare Fiscal Intermediary (FIs). o Each handoff ( )( should have been tested and verified PRIOR to October 1, 2012. o Your vendors MUST be aware of the requirement and MUST be working toward a timely solution. o Be aware that for some practice based EHRs the ASC component could be a lower priority. o If you have not done so, the time to speak with your vendors is today.
Include ASC Measure Reporting in Your Contingency Plans The Ball Drops October 1, 2012: Regardless of software vendor performance the requirement is the requirement. Develop and Test Contingency Plans: o Practices with EHRs typically have a paper protocol for use during power outages or other disaster situations. Make sure to include forms or other means to capture and document the requirements of the ASC Quality Measure program. o If your software vendor is not ready on October 1, 2012 be prepared to document the measure result for each patient on paper in such a way that it can later be incorporated into the electronic medical record. o Be prepared to train your clinical staff on contingency plans and the importance of compliance. o The most critical handoff ( ) is between the Clearing House and the Medicare FIs. o Explore and test methods to edit pre-clearing House billing batches to include the appropriate p G- codes should any of the handoffs ( ) fail. o Review in detail any billing batches created for dates of service on or after October 1for correct reporting until errors and rejections are eliminated.
Quality Measure Corresponding G-Code on CMS Form 1500 All four adverse events did not occur G8907 If one or more of the following events occurred, report the following: Patient Burn Patient Burn DID NOT OCCUR Patient Fall in the ASC facility Patient Fall in the ASC facility DID NOT OCCUR Wrong site/side/patient/procedure/implant G8908 G8909 G8910 G8911 G8912 Wrong site/side/patient/procedure/implant / i / d / DID NOT G8913 OCCUR Hospital Transfer/Admission G8914 Hospital Transfer/Admission DID NOT OCCUR Always Report One of the Following: Prophylactic IV antibiotic initiated ON TIME Prophylactic IV antibiotic initiated NOT ON TIME Patient Without Preoperative Order for Prophylactic IV Antibiotic G8915 G8916 G8917 G8918
When is reporting required for the prophylactic antibiotic measure? The measure denominator is Medicare FFS ASC admissions with a preoperative order for a prophylactic IV antibiotic for prevention of surgical site infection. The measure is whether the IV antibiotics were administered on time or not on time and should be reported for all required Medicare claims.
In circumstances when the patient is admitted to the ASC without a preoperative p order for a prophylactic p IV antibiotic, does not need an antibiotic, and no other reportable adverse events occurred with the patient, what code(s) should be reported? ASCs must report separately on the prophylactic IV antibiotic measure regardless to if the antibiotic was administered on time (G8916), not on time (G8917), or if the antibiotic was not ordered (G8918). If the patient did not experience any of the events (a burn prior to discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong procedure or wrong implant event; or a hospital transfer or hospital admission upon discharge from the facility), the ASC should report code G8907 in addition to one of prophylactic p IV antibiotic QDCs listed above. For example a patient that received no antibiotic, the ASC would report both G8907 and G8918 codes on the1500 claim form.
ASCs must report in 2013 whether their facility used a safe surgery checklist in 2012. Does this checklist have to be in place for the entire year? The safe surgery checklist use measure ascertains response to the following: Does/did your facility use a safe surgery checklist based on accepted standards of practice during the designated period? Yes/No. For the initial data collection (July 1 to August 15, 2013), the ASC can answer Yes if the checklist was used ANY time during 2012.
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.
Are pre-admission testing visits conducted in an ASC included for reporting purposes since they are not technically "ASC Admissions? A visit for a PAT is not considered an ASC admission for purposes of the ASC Reporting Program.
If the patient is registered and admitted to the ASC but is transferred to the hospital before any procedure, what code should we report? The facility would still report G8914. The transfer occurred after the patient was registered into the facility. Admission is after the patient enters the facility and upon the completion of the registration. Important to note that in this scenario, the facility may have to report a G-code on a Medicare claims form even if there is no service or corresponding CPT code. However, a claim with a zero charge may be rejected so the GI societies urge you to contact your Medicare contractor should this event occur.
Does the payment reduction affect the facility fees, the professional fees or both? The payment reduction affects ASC facility payment for services affected by Medicare s ASC annual payment update. It will not affect professional fees. The method for calculating the reduction and which fees are affected will be finalized in November 2012.
Can claims be resubmitted to correct quality measure data reporting? No. If claims for a service are submitted that do not change what is billed, then the claim will be rejected by the Medicare Administrative Contractor. Thus, there is no way to catch up or correct QDC reporting.
Anita Bhatia anita.bhatia@cms.hhs.gov CMS Program Lead Brad Conway bconway@gi.org ACG Vice President, Public Policy Elizabeth Wolf ewolf@gastro.org AGA Director, Regulatory Affairs Lakitia Mayo lmayo@asge.org y y g g ASGE Assistant Director, Health Policy and Quality