Quality Reporting for Your ASC: 2024 Final Changes

On November 2, 2023 the Centers for Medicare and Medicaid Services (CMS) released the 2024 Ambulatory Surgical Center Quality Reporting Program (ASCQR) Final Rule. This blog post breaks down the final changes to the ASCQR.

2024 Final Changes

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

• ASC-11: Cataract Improvement in Patient’s Visual Function Within 90 Days Following Cataract Surgery, will remain voluntary in all future years, subject to periodic CMS reevaluation.
• CMS has finalized a modification to this voluntary measure beginning in 2024, that will 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

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

• CMS will modify the 2024 definition of being “up to date” with COVID vaccination for this measure to align with CDC guidance over time.
• In order to be considered up to date healthcare providers must meet one of the following criteria:

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.

 

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

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

 

Final 2024 ASCQR Measure Set

ASC #	Measure Name	Mandatory/Voluntary
ASC-1	Patient Burn	Mandatory
ASC-2	Patient Fall	Mandatory
ASC-3	Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant	Mandatory
ASC-4	All-Cause Hospital Transfer/Admission	Mandatory
ASC-9	Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients	Mandatory
ASC-11	Cataracts Visual Function (Previously referred to as Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery)	Voluntary
ASC-12	Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy	Mandatory
ASC-13	Normothermia Outcome	Mandatory
ASC-14	Unplanned Anterior Vitrectomy	Mandatory
ASC-17	Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures	Mandatory
ASC-18	Hospital Visits after Urology Ambulatory Surgical Center Procedures	Mandatory
ASC-19	Facility-Level 7-Day Hospital Visits after General Surgery Procedures Performed at Ambulatory Surgical Centers	Mandatory
ASC-20	COVID-19 Vaccination Coverage Among Health Care Personnel	Mandatory

  

2025 Finalized Changes

Not Finalized: Re-adoption with Modification of the ASC Facility Volume Data on Selected ASC Surgical Procedures

CMS chose not to readopt ASC-7, the ASC Procedure Volume measure, at this time.

Finalized 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 adopted THA/TKA PRO-OM into the ASCQR Program with modifications for procedures performed in ASCs.
• Voluntary reporting periods will begin in 2025.
• CMS changed the year in which mandatory reporting will begin from 2027 to 2028.

 

Final 2025 ASCQR Measure Set

ASC #	Measure Name	Mandatory/Voluntary
ASC-1	Patient Burn	Mandatory
ASC-2	Patient Fall	Mandatory
ASC-3	Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant	Mandatory
ASC-4	All-Cause Hospital Transfer/Admission	Mandatory
ASC-9	Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients	Voluntary
ASC-11	Cataracts Visual Function (Previously referred to as Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery)	Voluntary
ASC-12	Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy	Mandatory
ASC-13	Normothermia Outcome	Mandatory
ASC-14	Unplanned Anterior Vitrectomy	Mandatory
ASC-15a-e	OAS CAHPS Measures	Mandatory
ASC-17	Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures	Mandatory
ASC-18	Hospital Visits after Urology Ambulatory Surgical Center Procedures	Mandatory
ASC-19	Facility-Level 7-Day Hospital Visits after General Surgery Procedures Performed at Ambulatory Surgical Centers	Mandatory
ASC-20	COVID-19 Vaccination Coverage Among Health Care Personnel	Mandatory
*New* ASC-21	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)	Voluntary (Mandatory starting in 2028)

 

Next Steps

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