2024 Proposed Changes to ASC Quality Reporting: What You Need to Know

On July 13, 2023 the Centers for Medicare and Medicaid Services (CMS) released the 2024 Ambulatory Surgical Center Quality Reporting Program (ASCQR) Proposed Rule. This blog post breaks down the proposed changes to the ASCQR and requests for feedback.

 

2024 Proposed Changes

Proposed Modification of Survey Instrument Use for the Cataracts: Improvement in Patient’s Visual Function Within 90 Days Following Cataract Surgery 

• CMS is not proposing any changes to voluntary status of this measure. ASC-11: Cataract Improvement in Patient’s Visual Function Within 90 Days Following Cataract Surgery, will remain voluntary. 
• CMS is proposing a modification to the voluntary measure beginning in 2024, that would limit the survey instruments that can be used to one of the following three: 
  • National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25)
    • Contains 25 questions
  • Visual Functioning Patient Questionnaire (VF-14)
    • Contains 18 questions covering 14 aspects of visual function affected by cataracts.
    • The link above contains a download from the NIH website
  • Visual Functioning Index Patient Questionnaire (VF-8R)
    • Contains 8 questions 
    • The link above contains a download from the American Academy of Ophthalmic Executives’ website

Proposed Modification of the COVID–19 Vaccination Coverage Among Health Care Personnel (HCP) 

• CMS is proposing to modify the definition of being “up to date” with COVID vaccination for this measure to align with CDC guidance overtime. 
• In order to be considered up to date healthcare providers must meet one of the following criteria: 

1. 1. Individuals who received their second dose in a two-shot primary vaccination series, (Pfizer-BioNTech or Moderna vaccines) less than 5 months ago. 
   2. Individuals who received a J&J/Janssen as their primary vaccination less than 2 months ago. 
   3. Individuals who have received a primary series and one booster dose when recommended.

Proposed Modification of Endoscopy/Polyp Surveillance: for Normal Colonoscopy in Average Risk Patients 

• CMS is proposing to modify this measure by lowering the age of screening colonoscopy to 45 (down from 50) to align with new recommendations from the U.S. Preventive Services Task Force (USPSTF) and the American Cancer Society. 

Proposed 2024 ASCQR Measure Set

 

2025 Proposed Changes

Proposed Re-adoption with Modification of the ASC Facility Volume Data on Selected ASC Surgical Procedures 

CMS is proposing to readopt ASC-7, the ASC Procedure Volume measure, as voluntary in 2025. ASC-7 was removed from ASCQR in 2018, but, with the recent shift of more surgical procedures to outpatient settings, and the linkage between procedure volumes and quality outcomes, CMS states this metric is an important data point for patients. 

Originally, ASC-7 tracked volume data in six categories, but now, with the addition of cardiovascular and respiratory, will track procedure volume in the following eight categories:

• Cardiovascular
• Eye
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Nervous System
• Respiratory
• Skin

Rather than collecting and publicly displaying general data surrounding each of these eight broad categories, CMS proposes to do so for only the top five most frequently performed procedures among ASCs within each category. The top five procedures would be assessed and updated annually. 

Finally, CMS proposes to make this measure mandatory beginning with the 2026 reporting period/2028 payment determination.

Proposed Adoption of the Risk Standardized Patient-Reported Outcome-Based Performance Measure (PRO-PM) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) in the ASC Setting (THA/TKA PRO-PM) 

• CMS is proposing to adopt THA/TKA PRO-OM into the ASCQR Program with modifications for procedures performed in ASCs. 
• Voluntary reporting periods will begin in 2025/2026. 
• Mandatory reporting will begin in 2027.

 

Proposed 2025 ASCQR Measure Set

 

Next Steps

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