Are You Ready for Quality Reporting?

This year marks the first time ASCs are required to collect and submit performance information to CMS.

By Desiree Ifft, Contributing Editor

Time is running out for ASCs to comply with the new Quality Reporting Program implemented by the Centers for Medicare & Medicaid Services (CMS). Beginning October 1 of this year, Medicare-participating ASCs are required to document and report to CMS whether or not each Medicare Part B fee-for-service patient experienced a fall, burn, transfer to a hospital, wrong-site/wrong side/wrong patient/wrong procedure/wrong implant surgery or improperly timed prophylactic intravenous (IV) antibiotic administration while in their care. Also this year, they are required to have a safe surgery checklistin place to keep track of the number of certain procedures, performed so they can report the information in 2013. Failing to comply with the program's requirements will result in reduced payments in subsequent years, starting in 2014.

The goal of the ASC Quality Reporting Program, as stated by CMS, is to promote high-quality care in the ASC setting and align quality of care across ASCs and hospital outpatient departments (HOPDs). Similar reporting programs are already up and running in other CMS payment systems, such as those for physicians and hospitals. Eventually, the information compiled under the various programs will be made available to the public as a means for comparing options in care.

Since Congress passed the Medicare Improvements and Extension Act of 2006, Division B of Title I of the Tax Relief and Health Care Act of 2006, the secretary of Health and Human Services has had the authority to establish a quality reporting program for ASCs. However, it wasn't finalized until adoption of the 2012 Outpatient Prospective Payment System (OPPS)/ASC Final Rule (CMS-1525-FC). At the urging of ASC industry groups, such as the Outpatient Ophthalmic Surgery Society (OOSS), CMS had postponed implementation of the program until facilities could gain some experience with the new ASC payment system, which took effect in 2008, before having to comply with additional federal requirements. (See From the Hill, page 20.)

The elements of the ASC Quality Reporting Program that require action by facilities this year and in 2013 are just the first stages of the program. Additional quality measures for future years will be put into effect later. CMS will periodically evaluate the usefulness of all the measures. The five claims-based quality measures for the program were developed by the ASC Quality Collaboration (ASC QC), a cooperative effort of organizations and companies interested in ensuring that ASC quality data is measured and reported in a meaningful way. These five measures are endorsed by the National Quality Forum.

To help ASCs prepare for compliance with the program, The Ophthalmic ASC asked ASC QC Executive Director Donna Slosburg, BSN, LHRM, CASC, and Lou Sheffler, one of three OOSS members in ASC QC's Leadership Group, to clarify key points.

Five Measures to be Reported Using G-Codes

Patient falls, patient burns, hospital transfer/admissions and wrong site/wrong side/wrong patient/wrong procedure/wrong implant measures are known as outcomes measures. They assess patients for a specific result of healthcare intervention. The timing of prophylactic IV antibiotic administration is known as a process measure. Process measures evaluate a particular aspect of the care that is delivered to the patient. ASCs will report on these measures using G-codes (Table 1) on their CMS-1500 billing forms, which they already submit for each Medicare beneficiary served. For these five measures, the information should be reported only for Medicare Part B fee-for-service beneficiaries who are admitted to the ASC, not all ASC patients. Claims for Part B fee-for-service patients who are treated at the ASC but not in an OR/procedure room, such as those having a YAG capsulotomy, must also include the G-codes. The G-codes should be used with a line-item charge of $0 rather than with the charge left blank.

Figure 1. This example of an ophthalmic-specific safe surgery checklist was developed by the Ophthalmic Mutual Insurance Company, the American Academy of Ophthalmology, the American Society of Cataract and Refractive Surgery, the American Society of Ophthalmic Registered Nurses and the Outpatient Ophthalmic Surgery Society.

According to ASC QC's Slosburg, one misconception that has emerged about the ASC Quality Reporting Program is that single-specialty facilities are exempt from reporting on the prophylactic antibiotic measure. “That any ASC is exempt from reporting at this time on this measure is inaccurate,” she says. “For patients who do not have a preoperative order for IV infection prophylaxis, which may be the case for more eye surgery patients than patients having other types of surgery, the G8918 code would be used on the CMS-1500.”

One of the challenges in developing quality measures for ASCs was to ensure they would meaningfully apply to the entire ASC industry, which encompasses a broad range of medical specialties. “We focused on outcomes and processes that ASCs could influence or impact, outcomes that ASCs would be aware of given the limited time they serve each patient, and outcomes that would be understandable and important to key stakeholders, including patients, physicians and payers,” Slosburg says. “Each of the measures may not be a priority in some single-specialty ASCs but may be in others. However, the measures involve events that can and do happen in all facilities.”

In addition to his role with ASC QC, Sheffler is CEO of American SurgiSite Centers, Inc., which manages and/or co-owns several ophthalmic ASCs. He lists some examples of how these claims-based quality measures would apply. “Tissue burns of the cornea that can occur during phaco, laser burns, and cautery burns that can occur during oculoplastic procedures would all be reportable events,” he says. “A scald, even from a nonmedical cause such as spilled coffee, should also be reported as a burn. Anesthetizing the wrong eye with a peribulbar block would be considered a wrong-side surgery; however, putting topical anesthetic drops in the wrong eye would not be.”

Slosburg reiterates that a main goal for the ASC QC is to develop quality measures that reflect what is within the control of the ASC. For example, if a call to check on a patient the day after her cataract surgery reveals she was taken to the hospital that morning, there's no need to include this in the current quality reporting program. Hospital transfer/admission is defined as “any transfer/admission from an ASC directly to an acute care hospital including hospital emergency room.” Similarly, if a patient falls in the ASC parking lot, the event would not be reported under this program. The measure specifies ASC admissions “experiencing a fall within the confines of the ASC.”

Sheffler says ASCs are concerned that properly submitting required information will be burdensome and detrimental to efficiency, but those who electronically chart shouldn't have too much trouble with the G-codes. “It may be more time-consuming for centers that use paper charts,” he says. “In that situation, someone would have to manually transfer the G-codes from the charts to the electronic CMS-1500 forms for billing.”

Two Measures to be Reported Online

In addition to the four outcomes measures and one process measure described above, the ASC Quality Reporting Program requires attention by ASCs this year on two structural measures: a safe surgery checklist (Figure 1) and the collection of volume data for a select list of procedures (Table 2). Structural measures assess whether a facility possesses conditions for the care of patients that are associated with better quality.

ASCs aren't required to submit their information on these two measures until July 1, 2013 through August 15, 2013; however, the information reported must cover the period January 1, 2012 to December 31, 2012. Data for the structural measures applies to all patients admitted to the ASC, not just Medicare Part B fee-for-service patients, and will be reported via a Web-based tool managed by QualityNet (www.qualitynet.org). Facilities will need to answer “yes” or “no” to the question of whether they utilized a safe surgery checklist during 2012 and also enter the total number of specified procedures performed. They can set up their accounts on QualityNet beginning in January 2013, but won't be able to report their information until July 1, 2013.

CMS is not requiring any specific checklist, but has stated that a checklist should address three critical perioperative periods: prior to administration of anesthesia, prior to skin incision, and prior to the patient leaving the operating room. In the 2012 Final rule, the agency cites as an example a checklist developed by the World Health Organization and adopted by The World Federation of Societies of Anesthesiologists as an international standard of practice (www.who.int/patientsafety/safesurgery/en/).

Some confusion has arisen about when a facility is required to have a safe surgery checklist in place, Slosburg said. The 2012 Final Rule specified a safe surgery checklist for the entire calendar year of 2012. “However, the subsequently released CMS ASC Quality Reporting Program Quality Measures Specifications Manual (See “Resources,” below) indicates that as long as an ASC had a checklist in place at any time during 2012, it can report ‘yes' on the measure,” she explains.

The safe surgery checklist in place at all of the ASCs partially owned or managed by American SurgiSite Centers is a page in their cloud-based electronic medical record/charting system. “Nowhere in the regulations does it say the checklist has to appear in the chart,” Sheffler says. “It can be in the ASC's log book or manual, for example, but we thought it best to include it in our chart. That way, it's part of the nursing workflow in the OR and pre-op area. Some consultants have recommended the checklist not be part of the chart, but if something went wrong, the event would have to be included there at some point anyway. We like it in the chart, so it can be completed as we go.”

Sheffler also points out that CMS hasn't specified who in the OR is supposed to document the checklist points in the OR. His team chose to make it the responsibility of the nursing staff employed in their facilities. They held in-service meetings to explain how the checklist should be used. They also met with the physicians who use the ASCs to help ensure their cooperation with what the nurses would be documenting in the OR.

For the surgical volume reporting measure, CMS identified eight categories that constitute the vast majority of procedures performed in ASCs: cardiovascular, eye, gastrointestinal, genitourinary, musculoskeletal, nervous system, respiratory and skin. In the eye category, ASCs will have to report their volume for eye transplants, laser procedures of the eye, glaucoma procedures, cataract procedures, injections of the eye, repairs of surrounding eye structures, and retinal, macular and posterior segment procedures.

Regarding the safe surgery checklist and volume data requirements, CMS has said it “highly recommends” that ASCs maintain a QualityNet administrator, but is not requiring it at this time.

Payment Reductions for Noncompliance

ASCs that aren't in compliance with the Quality Reporting Program will face a 2% reduction in their Medicare annual payment update in 2014 for the claims-based outcomes and process measures, and in 2015, for structural measures. Regarding the claims-based measures (to be reported this year and that would affect 2014 payments), the agency has proposed that ASCs will be considered successful reporters and receive their full payment if 50% of the relevant claims contain the quality measure G-codes. Also, CMS intends to propose an increase in this percentage for subsequent payment years.

Last year, the agency announced it would determine how the penalties would be imposed when its 2013 Final Rule is published.

Welcome to the Future

Because ASCs haven't had to report on quality measures in the past, the new rules may seem overwhelming, Slosburg said. Her advice to ASCs is to consider and plan for one requirement at a time, reading and understanding the CMS rules and communicating with ASC staff and physicians. Designating one person to lead the facility's efforts is a good idea as well, she said.

The current requirements base payments only on the proper submission of the information, not on the ASC's actual performance on the measures. However, the latter is on the horizon. Under the Affordable Care Act, Health and Human Services is developing a plan for implementing a value-based purchasing (i.e., pay for performance) program for Medicare-participating ASCs.

Sheffler says that while reporting responsibilities for ASCs will increase each year, there is a silver lining. A value-based purchasing program would give ASCs the opportunity to be financially rewarded for good performance. And, for now, “The ASC Quality Reporting Program will allow ASCs to be measured against hospitals. It will demonstrate for regulators what our industry already knows: ASCs are efficient, cost-effective venues for surgery and they have low complication rates.” ◊