Donna what's up in quality measures by James Rhymer

3/27/2015

What’s Up In Quality Measures

Donna Slosburg, RN, BSN, LHRM, CASC ASC Quality Collaboration Executive Director

Learning Objectives • Participants will: – Identify what quality reporting is required by Centers for Medicare and Medicaid Services (CMS) for ambulatory surgery centers (ASCs) – Define the quality measure requirements for ambulatory surgery centers – Understand future implications in the ambulatory surgery center quality reporting program

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ASCQR Program Measures Summary Number

ASC‐1 ASC‐2 ASC‐3

ASC‐4 ASC‐5

Measure Title

Type of Measure

Data Collection Dates

Patient Burn

Claims‐Based January 1‐ December 31, 2014 January 1‐ December 31, 2015 Patient Fall Claims‐Based January 1‐ December 31, 2014 January 1‐ December 31, 2015 Wrong Site, Wrong Side, Claims‐Based January 1‐ December Wrong Patient, Wrong 31, 2014 Procedure,Wrong Implant January 1‐ December 31, 2015 Hospital Claims‐Based January 1‐ December Transfer/Admission 31, 2014 January 1‐ December 31, 2015 Prophylactic Claims‐Based January 1‐ December Intravenous (IV) 31, 2014 Antibiotic Timing January 1‐ December 31, 2015

Data Reporting Dates

Payment Affected Groups Determination Year January 1‐ December CY 2016 Medicare Part B fee 31, 2014 for service patients January 1‐ December CY 2017 31, 2015 January 1‐ December CY 2016 Medicare Part B fee 31, 2014 for service patients January 1‐ December CY 2017 31, 2015 January 1‐ December CY 2016 Medicare Part B fee 31, 2014 for service patients

January 1‐ December 31, 2015 January 1‐ December 31, 2014 January 1‐ December 31, 2015 January 1‐ December 31, 2014

CY 2017

CY 2016

Medicare Part B fee for service patients

CY 2016

Medicare Part B fee for service patients

January 1‐ December 31, 2015

CY 2017

ASCQR Program Measures Summary Number

Measure Title

ASC‐6

Safe Surgery Checklist Use

ASC‐7

ASC Facility Volume Data on Selected ASC Surgical Procedures

ASC‐8

Influenza Vaccination Coverage among Healthcare Personnel

Type of Measure

Data Collection Dates

Data Reporting Dates

Payment Affected Groups Determination Year CY 2016 All patients

Web‐Based via QualityNet secure portal

January 1‐ December 31, 2014

January 1‐ August 15, 2015

January 1‐December 31, 2015

January 1‐ August 15, 2016

CY 2017

Web‐Based via QualityNet secure portal

January 1‐ December 31, 2014

January 1‐ August 15, 2015

CY 2016

All patients

January 1‐December 31, 2015

January 1‐ August 15, 2016

CY 2017

Web‐Based via NHSN

October 1, 2014‐ March 31, 2015

Through May 15, August 15, 2015

CY 2016

Health Care Personnel

October 1, 2015‐ March 31, 2016

Through May 15, 2016

CY 2017

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ASCQR Program Measures Summary Number

ASC‐9

Endoscopy/Polyp Surveillance: Appropriate Follow‐Up Interval for Normal Colonoscopy in Average Risk Patients

ASC‐10

Measure Title

Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use

ASC‐11 Cataracts‐ Improvement in Voluntary Patient’s Visual Function within 90 days following Cataract Surgery ASC‐12 Facility Seven‐Day Risk Standardized Hospital Visit Rate after Outpatient Colonoscopy

Type of Measure

Data Collection Dates

Web‐Based via April 1‐ QualityNet December 31, 2014 secure portal

January 1‐ December 31, 2015 Web‐Based via April 1‐ QualityNet December 31, 2014 secure portal

Data Reporting Dates

February 1‐ August 15, 2015

Payment Affected Determination Groups Year CY 2016 Sampling

January 1‐August 15, 2016 February 1‐ August 15, 2015

CY 2017

CY 2016

Sampling

January 1‐ January 1‐August 15, December 31, 2015 2016 Web‐Based via January 1‐ January 1‐ August 15, QualityNet December 31, 2015 2016 secure portal

CY 2017

Administrative Claims‐Based

Paid Medicare Fee Paid Medicare Fee for for Service Claims Service Claims from (to be determined)

Will not affect Sampling payment; voluntary CY 2018

Paid Medicare Fee for Service Claims

CMS Ambulatory Surgical Center Quality Reporting Program • CMS ASC Quality Reporting Program Quality Measures Specifications Manual • Verify you have the latest version- 4.0a (December 2014)

• Located @ www.qualitynet.org under ASC tab • Included in this manual: • Measure specifications • Data collection and submission • Quality Data Codes (QDCs) 6

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ASC Quality Reporting Program • 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*

Claims Based Reporting–Quality Data Codes (QDCs) on CMS 1500 *Data submission began in CY 2012. 7

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/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

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Participation and Non Participation • 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 9

Extraordinary Circumstance Extension or Exemptions Request 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 10

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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

ASC Quality Reporting Program • 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 System/Respiratory/Skin/MultiSystem} 12

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ASC 6: Safe Surgery Checklist Use  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 – The period of closure of incision and prior to the patient leaving the operating room

 Applies to all ASCs, including single specialty centers

ASC 6: Safe Surgery Checklist Use All Patients 2014 • Data collection: January 1-December 31, 2014 • Data reporting: “Yes” or “No” on www.qualitynet.org between January 1 through August 15, 2015 2015 • Data collection: January 1-December 31, 2015 • Data reporting: “Yes” or “No” on www.qualitynet.org between January 1 through August 15, 2016 14

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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/CorrectSite SurgeryToolKit/Comprehensivechecklist/

ASC 7: 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 16

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Organ System Eye

Gastrointestinal

CMS Procedure Category

Surgical Procedure Codes

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

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

Musculoskeletal

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

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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. 19

ASC 7: Volume of Selected Procedures All Patients: 2014 • Data collection: January 1-December 31, 2014 • Data reporting: Selected Procedure Categories on www.qualitynet.org between January 1 through August 15, 2015 2015 • Data collection: January 1-December 31, 2015 • Data reporting: Selected Procedure Categories on www.qualitynet.org between January 1 through August 15, 2016 20

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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 QualityNet Secure Portal (www.qualitynet.org) – – – –

Safe Surgery Checklist Use ASC Volume of Selected Procedures for all-patients Endoscopy Surveillance: Appropriate follow-up for Normal Colonoscopy Endoscopy Surveillance: Colonoscopy Interval for History Adenomatous Polyps

• 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 21

ASC Program Measurement Set for 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 System/Respiratory/Skin/Multi System} • ASC- 8: Influenza Vaccination Coverage among Healthcare Personnel * *New measure for CY 2016 payment determination 22

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ASC 8: Influenza Vaccination Coverage among Healthcare Personnel (HCP)  Intent: assess the percentage of HCP immunized for influenza during the flu season  Three 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  Deadline for data reporting for the 2014-2015 flu season is May 15 August 15, 2015. 23

ASC 8: Influenza Vaccination Coverage among Healthcare Personnel (HCP)  CDC’s NHSN website for 5 step enrollment: www.cdc.gov/nhsn/ambulatory-surgery/enroll.html “NHSN facility administrator enrollment guide”

 Need to complete the 3 step Set-up (http://www.cdc.gov/nhsn/ambulatory-surgery/setup.html ) before reporting!  Reporting data to CDCs National Healthcare Safety Network (NHSN) requires (https://sams.cdc.gov ) user authorization through Secure Access Management Services (SAMS)) for access to NHSN. 24

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The NHSN Website: http://www.cdc.gov/nhsn Click on New to NHSN

Click on Ambulatory Surgery Centers

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NHSN 5 Step Enrollment Process Step 1: Training and Preparation

NHSN Enrollment Process Steps 2-5 • Read and accept NHSN rules of behavior AND register with NHSN (step 2) • Register with SAMS (step 3) • 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 facility forms electronically (step 4) • Sign and send consent (step 5) 28

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Secure Access Management Services (SAMS) https://sams.cdc.gov

Click on NHSN Set Up

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NHSN Set Up: Required before Reporting to SAMS

NHSN Set Up 3 Step Process: Create Location, Create Your Plan and Add Users

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Report to NHSN via Secure Access Management Services (SAMS) https://sams.cdc.gov {user authorization is required for access}

Influenza Vaccination Summary Employee HCP Employees (staff on facility payroll)

Non-Employee HCP Licensed independent practitioners: Physicians, advanced practice nurses, & physician assistants

Adult students/ trainees & volunteers

Other contract personnel

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 34

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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

Numerator Categories • Influenza vaccinations – Received at this healthcare facility – Received elsewhere

• Medical contraindications • Declinations • Unknown status

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

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 QualityNet Secure Portal (www.qualitynet.org) – – – –

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Training Webinars for NHSN • The CDC conducted a live training webinar in August to cover the requirements for collecting and entering HCP influenza vaccination summary data. • A recording of the webinar is posted at: http://www2.cdc.gov/vaccines/ed/nhsn/ so ASC staff can review the recorded training and slides at any time if they were unable to attend the webinar.

NHSN Questions • For questions on HCP influenza vaccination summary reporting, please send an e-mail to: NHSN@cdc.gov and include “HPS Flu Summary-ASC” in the subject line • For assistance with SAMS, contact the SAMS Help Desk @ 1-877-681-2901 or samshelp@cdc.gov

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2014 Medicare Hospital Outpatient Prospective Payment System (OPPS)/ASC Payment Final Rule • 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) 41

ASC Measures for CY 2016 Payment Determination • 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) 42

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ASC 9: Endoscopy/Polyp Surveillance: Normal Colonoscopy  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 43

ASC 9: Endoscopy/Polyp Surveillance: Normal Colonoscopy  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) 44

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ASC 10: Endoscopy/Polyp Surveillance: Adenomatous Polyp  Denominator: number of patients 18 years and older receiving a surveillance colonoscopy with a history of a prior colonic polyp in a previous colonoscopy findings  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. 45

ASC 10: Endoscopy/Polyp Surveillance: Adenomatous Polyp  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)

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ASC 10: Endoscopy/Polyp Surveillance: Adenomatous Polyp • 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 47

(The ICD-9 codes will be updated when the conversion to ICD-10 occurs)

ASC 11: Cataract: Improvement in Patients Visual Function within 90 days Voluntary  Denominator: number of patients aged 18 years and older in sample who had cataract surgery and completed both a pre-operative and postoperative 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 preoperative and post-operative visual function instrument 48

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ASC 11: Cataract: Improvement in Patients Visual Function within 90 days Voluntary  Exclusions: Patients who did not complete both a pre-operative and post-operative survey  Inclusions: Patients aged ≥18 years AND CPT (with or without modifiers): 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984

ASC 11: Cataract: Improvement in Patients Visual Function within 90 days Voluntary Definition for Survey: •The data collection instrument is specified as an assessment tool that has been appropriately validated for the population for which it is being used. •The same data collection instrument used pre-operatively should be used post-operatively. The surveys can be completed by phone, mail, or email during physician follow-up. •The ASC will be required to obtain the assessment outcome from the operating physician’s office. {this is changing with an addendum in the next specifications manual}

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ASC 11: Cataract: Improvement in Patients Visual Function within 90 days Voluntary The following links are provided on the www.qualitynet.org website and specifications manual to locate the Visual Function Survey examples: •National Eye Institute http://www.fivepointseyecare.com/user_files/1284573435_NEI%20Visual %20Functioning%20Questionnaire.pdf •Information from the American Academy of Ophthalmology http://www.aao.org/aaoe/practice-management/upload/PQRSMeasure303.pdf •VF-8R Form http://ascrs.org/sites/default/files/resources/2013%20Cataracts%20Measu res%20Group%20Post-Surgery%20VF-8R_0.pdf •Catquest-9 Form http://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/OPX/ A/OPX_90_8_2013_04_04_LUNDSTROM_201940_SDC1.pdf •VF-14 Form http://www.med.teikyo-u.ac.jp/~ortho/med/reh/VF-14.html 51

Resources and tools for endoscopy and cataract measures

http://www.qualityreportingcenter.com/resources/tools/asc/

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Sampling Size Specifications ASC-9, ASC-10 or ASC-11 voluntary 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

â&#x2030;Ľ901 96 24 8

Examples of Sample Size If you performed 950 Screening Endoscopies Sample size would be 96 If you performed 43 Screening Endoscopies Sample size would be 43 If you performed 800 Biopsy or Polypectomy Endo Sample size would be 63 If you performed 1200 Cataracts Sample size would be 96 54 {Each measure volume will determine the sample size.}

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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 QualityNet Secure Portal (www.qualitynet.org) – – – –

ASC 9, ASC 10 and ASC 11 voluntary • ASC 9 and 10: Data collection April 1-December 31, 2014 Data reporting January 1-August 15, 2015 • 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 www.qualitynet.org secure portal and enter zero • ASC-11 is not in the secure portal this year. If you elect to collect the information this year (January 1- December 31, 2015) and enter it next year (January 1- August 15, 2016), ASC-11 will be there, but you will not be penalized if you do not enter ASC-11 • ASC-11 is a voluntary measure however any data submitted will be publicly reported 56

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2015 Medicare Hospital Outpatient Prospective Payment System (OPPS)/ASC Payment Final Rule • Released October 31, 2014 • http://www.gpo.gov/fdsys/pkg/FR-2014-0714/pdf/2014-15939.pdf • ASC Quality Reporting Program begins on page 41044: Section XIV. Requirements for ASC Quality Reporting Program

New ASC Measures Finalized for CY 2018 and Subsequent Payment Determination Years • Previous ASC 1- ASC 10 plus • ASC 11: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery (NQF #1536) confirmed voluntary • 1 Additional Measure: ASC 12: Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy NQF = National Quality Forum (www.qualityforum.org) 58

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ASC 12: Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy • • • • •

Administrative Claims based measure No additional data submission from ASCs Utilizes paid Medicare Fee for Service (FFS) claims Finalized for CY 2018 payment determination This data is used to determine whether a beneficiary has had a hospital visit within seven days of the colonoscopy. • The colonoscopy measure score is an all-cause, unplanned hospital visit (admissions, observation stays, and emergency department [ED] visits) within seven days of an outpatient or ASC colonoscopy

ASC 12: Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy • Facility-specific dry run reports will be accessible via QualityNet (www.qualitynet.org) for ASCs to review : – 3 years of data (dates to be determined) – confidential reports of facility data prior to any future public reporting – colonoscopy measure methodology and their results confidentially • Confidential reports will include patient level data that could identify potential gaps for quality improvement efforts • Need to have an active Security Administrator in order to be able to receive these confidential reports because they will be sent via secure file exchange on the QualityNet Secure Portal. • The minimum volume of colonoscopies performed or cutoff volume will be determined 60

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In Summary: Key Points to Remember • Sign in to QualityNet secure portal every 60 days to keep the account active • ASC 7 (volume data measure): need to fill in all procedures listed in QualityNet even if your volume is zero • ASC 8 (influenza vaccination): need to enroll with CDC NHSN • ASC 9 and 10 (colonoscopy measures): need to fill in the numerator and denominator even if the number is zero and your facility does not perform colonoscopies 61

QualityNet Reports • Webinar presented on October 22, 2014 “Secure File Transfer and QualityNet Reports” • Slides and transcript can be accessed at http://www.qualityreportingcenter.com/events/archive/asc/ • Secure Administrator • Log on to secure portal • Go to ‘My Tasks’ page and the ‘My Reports’ • Two types of reports: – Claims Detail report – Provider Participation report 62

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Running Reports in Quality Net Secure Portal

Claims Detail and Participation Reports

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Claims Detail Reports • Assists your facility in monitoring compliance with claimsbased measures • Provide a list of claims submitted with and without Quality Data Codes (QDCs) • Lists claims that have been successfully submitted to the Medicare Administrative Contractor (MAC) in accordance with program requirements • Select parameters (dates) for your report

Participation Reports • Security Administrator (active: yes or no) • Participation Status (participating or withdrawn) • Claims • Data Completeness • CMS Threshold (%) • Web based measures (6 and 7) completed columns

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Additional Questions Contact HSAG (formerly FMQAI) for Program Questions at https://cms-ocsq.custhelp.com/ 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 qnetsupport@hcqis.org or via phone (866) 288-8912 Monday through Friday,

7 a.m. to 7 p.m. Central Time 67

CMS/HSAG (formerly FMQAI) Webinar May 27, 2015: Understanding Web-Based Measures This webinar will be at 2pET Registration & handouts will be posted at www.qualityreportingcenter.com (previously www.oqrsupport.com ) one week prior to the call

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CMS Focus for Future Measures In considering future measures, CMS is focusing on the following : • make health care safer • strengthen person and family engagement • promote effective communication and coordination of care • promote effective prevention and treatment • work with communities to promote best practices of healthy living • make health care affordable

Measures Under Consideration • Outpatient and Ambulatory Patient Experience of Care Survey Instrument • Normothermia – ASC patients receiving general, spinal or epidural anesthesia lasting 60 minutes or greater are normothermic (96.8F) within 15 minutes of arrival to the PACU

• Unplanned anterior vitrectomy – ASC patients having cataract surgery who have experienced an unplanned anterior vitrectomy

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Experience of Care Survey Instrument The Centers for Medicare & Medicaid Services (CMS) has developed a patient experience of care survey for patients who had surgery or a procedure at a hospital outpatient department (HOPD) or an ambulatory surgery center (ASC) Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) formerly Outpatient and Ambulatory Surgical Patient Experience of Care Survey (O/ASPECS) 71

Experience of Care Survey Instrument The survey measures patients’ experiences on topics that are important when choosing a place for their surgery or procedure, such as: • communication and care provided by health • care providers and office staff, • preparation for the surgery or procedure, • post-surgical care coordination, and • patient-reported outcomes.

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Experience of Care Survey Instrument Submitted to the Measure Application Partnership (MAP) as five measures: • X3697 Discharge and Recovery • X3698 About Facility and Staff • X3699 Communication • X3702 Overall Facility Rating • X3703 Would You Recommend MAP recommendation: Encourage further development Voluntary participation in 2016 73

Normothermia Outcome Intent: To capture whether patients having surgical procedures under general or neuraxial anesthesia of 60 minutes or more in duration are normothermic within 15 minutes of arrival in PACU Numerator: Surgery patients with a body temperature equal to or greater than 96.8 Fahrenheit/36 Celsius recorded within fifteen minutes of Arrival in PACU Denominator: All patients, regardless of age, undergoing surgical procedures under general or neuraxial anesthesia of greater than or equal to 60 minutes duration Numerator Exclusions: None Denominator Exclusions: Patients who did not have general or neuraxial anesthesia; patients whose length of anesthesia was less than 60 minutes; patients with physician/APN/PA documentation of intentional hypothermia for the procedure performed 74

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Normothermia Outcome Data Sources: ASC medical records, as well as anesthesia administration and nursing records may serve as data sources. Clinical logs designed to capture information relevant to normothermia are also potential sources. Definitions: Arrival in PACU: Time of patient arrival in PACU Intentional hypothermia: A deliberate, documented effort to lower the patient's body temperature in the perioperative period Neuraxial anesthesia: Epidural or spinal anesthesia Temperature: A measure in either Fahrenheit or Celsius of the warmth of a patient's body. Axillary, bladder, core, esophageal, oral, rectal, skin surface, temporal artery, or tympanic temperature measurements may be used. 75

Unplanned Anterior Vitrectomy Intent :To determine the number of cataract surgery patients who have an unplanned anterior vitrectomy Numerator: All cataract surgery patients who had an unplanned anterior vitrectomy Denominator: All cataract surgery patients Numerator Exclusions: None Denominator Exclusions: None

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Unplanned Anterior Vitrectomy Data Sources: ASC medical records, as well as incident/occurrence reports, and variance reports are potential data sources. Definitions: Admission: completion of registration upon entry into the facility Cataract surgery: for purposes of this measure, CPT code 66982 (Cataract surgery, complex), CPT code 66983 (Cataract surgery w/IOL, 1 stage) and CPT code 66984 (Cataract surgery w/IOL, 1 stage) Unplanned anterior vitrectomy: an anterior vitrectomy that was not scheduled at the time of the patient's admission to the ASC 77

Measures for Future Consideration • Postoperative nausea and vomiting • Toxic Anterior Segment Syndrome (TASS) • All cause hospital admission within 2 days of discharge • All cause emergency department visit within 2 days of discharge • Culture of Safety Survey

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Websites with Additional Information • ASC Quality Collaboration website (measure summary and implementation guide) http://ascquality.org/qualitymeasures.cfm • Ambulatory Surgery Center Association (ASCA) website http://www.ascassociation.org • QualityNet website (CMS Specifications Manual & Email Notifications) http://qualitynet.org • Quality Reporting Center FMQAI/HSAG (CMS national support contractor) http://www.qualityreportingcenter.com/

References  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. 221 / Thursday, November 15, 2012 / Rules and Regulations. Available at http://www.gpo.gov/fdsys/pkg/FR-2012-11-15/pdf/201226902.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/201328737.pdf  Federal Register / Vol. 79, No. 217 / Monday, November 10, 2014/ Rules and Regulations. Available at www.gpo.gov/fdsys/pkg/FR-2014-11-10/pdf/2014-26146.pdf  ASC Quality Collaboration Implementation Guide, Version 3.0, January 2015. Available at http://ascquality.org/documents/ASC_QC_ImplementationGuide_3.0_January_2015.pdf  CMS ASC Quality Reporting Program Quality Measures Specifications Manual, Version 4.0a, December 2014. Available at www.qualitynet.org  QualityNet at www.qualitynet.org  QualityReportingCenter at www.qualityreportingcenter.com  National Healthcare Safety Network www.cdc.gov/nhsn/

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Contact Information

Donna Slosburg, RN, BSN, LHRM, CASC ASC Quality Collaboration (ASC QC) Executive Director donnaslosburg@ascquality.org

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