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Ambulatory Surgical Center Profiler

Quality Data

The Ambulatory Surgical Center Quality Reporting (ASCQR) Program is a pay-for-reporting, quality data program finalized by the Centers for Medicare & Medicaid Services (CMS). Under this program, ASCs report quality of care data for standardized measures to receive the full annual update to their ASC annual payment rate.

For reporting in 2020, there are four measures required for eligible Medicare-certified facilities to avoid Medicare payment reductions in 2021. ASCs that have fewer than 240 Medicare claims (primary plus secondary payer) per year during a reporting period for a payment determination year would not be required to participate in the ASCQR Program for the subsequent reporting period for that subsequent payment determination year.

ASC-1: Patient Burn
The number of patients who experience a burn prior to discharge from the ASC.
ASC-2: Patient Fall
The number of patients who experience a fall within the ASC.
ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant
The number of patients who experience a wrong site, side, patient, procedure, or implant.
ASC-4: All-Cause Hospital Transfer/Admission
The percentage of ASC patients who are transferred or admited to a hopsital upon discharge from the ASC.
ASC-9: Endoscopy/Polyp Surveillance
Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients is a web-based measure that is reported via QualityNet. This aggregate data must be reported by all Medicare-certified ASCs, regardless of specialty or case mix.
ASC-11: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery
This is a voluntary measure. If an ASC chooses to participate in reporting this voluntary measure, any data reported will become publicly available.
ASC-12: Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy
Data are taken from claims previously submitted by the hospital that the patient visits within seven days of the colonoscopy. The ASC does not need to report this measure.
ASC-13: Normothermia
This measure assesses the percentage of patients having surgical procedures under general or neuraxial anesthesia of 60 minutes or more in duration who are normothermic within 15 minutes of arrival in PACU. Like ASC-9, this is a sampling measure.
ASC-14: Unplanned Anterior Vitrectomy
This measure is used to assess the percentage of cataract surgery patients who have an unplanned anterior vitrectomy.

CMS contracted with RTI International to develop the Outpatient and Ambulatory Surgery (OAS) Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey to measure the experience of care for patients who have a surgery or procedure performed in a hospital outpatient department (HOPD) or ambulatory surgery center (ASC). Prior to OAS CAHPS, which has been in development since 2012, there was no standardized survey instrument to assess patient experience with outpatient surgical care received at HOPDs and ASCs. The survey is currently voluntary and CMS decided to keep it voluntary until further rulemaking.