CMS Makes Changes to its Quality Reporting Program What this means for your ASC BY KARA NEWBURY

The Centers for Medicare & Medicaid Services (CMS) made significant changes to Medicare’s ASC Quality Reporting (ASCQR) Pro-

gram for 2019 and beyond, including the suspension of four outcomes measures that have been part of the ASCQR Pro- gram since its inception in 2012. Facili- ties that have been collecting and report- ing data on Medicare claims forms are no longer required to do so for 2019. Even though facilities no longer have to report on patient burns (ASC-1), falls (ASC-2), wrong events (ASC-3) or hospital transfers (ASC-4) on fee- for-service (FFS) Medicare claims, it is a good idea to continue collecting this data, as the measures have been sus- pended only instead of removed and the information can be useful for bench- marking and quality assessment and performance improvement.

What exactly did CMS say about ASC-1 through ASC-4 in the 2019 payment rule cycle? In the 2019 ASC proposed payment rule, CMS indicated that ASC-1 through ASC-4 had “topped out,” meaning the outcomes being reported by facilities were very high. CMS proposed to elim- inate these measures from the ASCQR Program, as the agency felt the data had limited value. Instead of remov- ing the measures from the ASCQR Pro- gram, however, in the 2019 final pay- ment rule CMS chose to suspend the measures, indicating they could be rein- stated in future years. CMS noted in the final rule that since these adverse events were only being collected as Qual- ity Data Codes (QDCs) on FFS Medi- care claims, adverse events that occur outside of the FFS Medicare popula- tion were not reported. CMS indicates that while it is suspending these mea-


sures, as the agency develops “future revisions for the data collected for these measures,” it will “take into consid- eration other data submission meth- ods that may allow for the reporting of adverse events across payers and will consider commenters’ feedback toward the future updates to the measures.” CMS also believes that reporting through a web-based mechanism such as QualityNet, the portal used for other ASCQR Program measures, errors could more easily be corrected by facil- ities. When submitting on claims, ASCs that identify an erroneous or missing QDC code are unable to correct or add a QDC code if the claim has already been submitted to Medicare. In the final rule, CMS states that “revising the data submission method for the measures, such as via QualityNet, would address this issue and allow facilities to correct any data submissions errors, resulting in more complete and accurate data.” The agency is sensitive to administra- tive burden on facilities, however, stat- ing that it is “committed to work with stakeholders to ensure the ASCQR


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Program measure set does not place an inappropriate amount of burden on facilities while addressing and provid- ing information about these types of patient safety, adverse, rare events to patients and other consumers.”

What does all of this mean to my facility? ASCs do not need to put QDCs on their FFS Medicare claims for 2019. Period. However, as indicated in the final rule text cited above, CMS is evaluating whether this data should be collected in the future, if it should be expanded to all payers and through what mechanism it would be reported in the future. The ear- liest this reporting could be mandated for ASCs would be 2020, and we will see in July whether it is proposed in the 2020 payment rule. Considering it would take the agency some time to evaluate the burden associated with implement- ing data reporting for all patients under a web-based portal such as QualityNet, it might be 2021 or beyond before we see these measures mandated again.

So why should we collect it? For the same reason you should still be using a safe surgical checklist, even though you no longer need to report on its usage under the ASCQR Program. It is important information for the facility to have to be able to address issues as they arise and benchmark against other facilities.

If I choose to continue reporting, where can I do that? As with many other data points that facilities are collecting on their own that are not required by state or federal government, ASCs can choose to con- tinue collecting through excel spread- sheets, their electronic health records or paper records. If you want to report this

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