Quality Reporting for Your ASC: 2022 Proposed Changes

On August 4, 2021 the Centers for Medicare and Medicaid Services (CMS) officially published the 2022 Ambulatory Surgical Center Quality Reporting Program (ASCQR) Proposed Rule. This blog post breaks down the proposed changes to the ASCQR for 2022 and beyond.

2022 Proposed Changes

The only major proposed change for 2022 ASCQR is the proposed addition of a new measure, COVID-19 Vaccination Among Health Care Personnel (HCP). This would measure the percent of HCP eligible to work in the ASC for at least one day during the reporting period who received a complete COVID-19 vaccination course. The proposed measure specification lists an exception for those with contraindications to COVID-19 vaccination that are described by the CDC.

If finalized, for the 2022 reporting period, measure data would need to be collected, submitted, and scored as follows:

  • Collect: ASCs would need to collect numerator and denominator data this measure for at least one self-selected week during each month of the reporting quarter.
  • Submit: Before the end of each quarter, ASCs would need to submit this data to the NHSN Healthcare Personal Safety (HPS) Component.
  • Score: The CDC would then calculate a single quarterly COVID-19 HCP vaccination rate for each ASC using the average of the ASC’s submitted data from that quarter. CMS would then publish this rate.

Analysis: Although this measure would, to some extent, increase ASCQR reporting burden, most ASCs should be familiar with the NHSN system from the old ASCQR Influenza Immunization measure. Given the close contact between HCP and patients in ASCs, risk of COVID-19 transmission is high for both HCPs and patients. CMS is proposing this measure to ensure that ASCs are “taking steps to limit the spread of COVID-19”. Given the high priority placed on this, and the time-sensitive nature of the pandemic, this proposed measure is likely to be finalized.

2023 Proposed Changes

CMS is proposing significant changes to the ASCQR requirements for the 2023 reporting period.

  • Proposing to bring back ASC-1, 2, 3, and 4.
    • Data collection on these measures was suspended in 2019 rule because the measures were topped out and because the data submission method, which involved adding specific QDCs onto eligible claims, was impacting the completeness and accuracy of the data.
    • For 2023, CMS proposes requiring providers to submit measure data via the HQR System (formerly referred to as the QualityNet Secure Portal), rather than via claims.
  • Proposing to require reporting on ASC-11: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery.
    • This measure has been voluntary for years.
    • Ophthalmic specialty societies have opposed this due to the inappropriate nature of these surveys being attributed to the ASC facility rather than to the individual surgeon and the burdensome nature of patient surveys, particularly in this context. This would require the ASC to report on data that is located in the surgeon’s office and, thus, inaccessible by the ASC as, per Medicare ASC Conditions for Coverage, the two entities must be physically, administratively, and financially separate from one another.
    • We anticipate this proposal will be challenged.
  • Proposing to allow voluntary reporting of ASC-15a-e: Outpatient Ambulatory Surgery (OAS) CAHPS Survey measure.
    • CMS is proposing additional collection modalities using a web-based module (web with mail follow-up of non-respondents and web with telephone follow-up of non-respondents) for administering the survey. CMS believes this will address concerns about burden and cost of survey administration.

2024 Proposed Changes

CMS is proposing to require reporting of the OAS CAHPS Survey measure. This measure is burdensome. Many ASCs struggle to convince patients to complete any surveys, let alone lengthy 37 to 52 question surveys. We anticipate there will be significant opposition to this proposal.