By Don Sadler

In 2012, the Centers for Medicare and Medicaid Services (CMS) established a uniform quality reporting system that enabled ambulatory surgery centers (ASCs) to demonstrate their performance on several quality measures developed based on years of rigorous review and testing. This program is referred to as the Ambulatory Surgical Center Quality Reporting (ASCQR) program.

Each year, when CMS issues updates to its final payment rule for ASCs and hospital outpatient departments (HOPDs) for the coming year, it includes updates to the data collection, data submission and program administration requirements ASCs need to be in compliance with Medicare’s ASCQR reporting program. ASCs that do not meet these requirements can experience future reductions in their Medicare reimbursement.

CMS released its final 2019 payment rule for ASCs and HOPDs on November 2, 2018.

The Specs Manual

“In 2012, we asked CMS to give us a document that was easy to read and use,” says Gina Throneberry, RN, MBA, CASC™, CNOR, the Director of Education and Clinical Affairs for the Ambulatory Surgery Center Association (ASCA).

The result was a CMS ASC Quality Reporting Program Measures Specification Manual, or the Specs Manual for short. “This is the guide for the program,” says Throneberry. “I highly recommend that ASCs read the specs manual thoroughly.”

The Specs Manual can be downloaded under the ASC tab at www.qualitynet.org. Included in the manual are measure specifications, data collection and submission, and Quality Data Codes (QDC).

There have been many versions of this manual since 2012, says Throneberry, so it’s critical to make sure you’re using the right one. Measures that are suspended remain in the CMS ASCQR program and could possibly return in the future. Measures that are deleted no longer remain in the program.

The final payment rule for 2019 removed a total of two quality reporting measures and suspended four measures across calendar years 2020 and 2021 for payment determinations. “Remember that collecting, reporting and payment determination is a two-year process,” says Throneberry.

Specifically, ASC-8 and ASC-10 will be removed for these two calendar years. “However, you should make sure this data isn’t required by your state,” says Throneberry. Meanwhile, to qualify for a full payment update in 2020, ASCs must report the data collected in 2018 on measures ASC-9 and ASC-10 by May 15, 2019.

ASC-11 has been voluntary for several years and will remain so, while implementation of ASC 15a-e (OAS CAHPS Survey measures) will continue to be delayed. And CMS is changing the reporting period for ASC-12 from one to three years. There is no data submission or reporting required from the ASC for ASC-12. Data is pulled by CMS from the Medicare Fee For Service administrative claims that were billed by the ASC starting January 1-December 31, 2016 and subsequent years.

Data collection for ASC-1, ASC-2, ASC-3 and ASC-4 is being suspended starting on January 1, 2019, until further rulemaking. “Also, ASCs no longer have to report data for ASC-5, ASC-6 and ASC-7,” says Throneberry.

“However, I recommend still collecting this data internally in case it’s needed for some other project or survey, such as an internal quality assurance performance improvement program or if you participate in benchmarking surveys,” she adds. “This is still considered a best practice.”

And starting this year, ASCs must begin reporting information they began collecting in 2018 on two new measures: ASC-13 and ASC-14.

Significant Changes This Year

In an interview published on the ASCA website in November, ASCA CEO William Prentice said that the changes included in this year’s final payment rule are among the most significant he has seen in his eight years with ASCA.

“I would say the changes demonstrate greater recognition of the quality and value that ASCs provide than we have seen in any previous rulemaking,” said Prentice.

For example, the changes include a decision to update ASC payments using the hospital market basket inflation factor for calendar years 2019 through 2023. “This is a much more realistic indicator of rising costs in the ASC space than what CMS has been using,” said Prentice. “We have fought for this change over the last decade and appreciate that it has been adopted.”

Prentice explains that changes in annual inflationary adjustments for ASCs will now be based on the hospital market basket, instead of the Consumer Price Index for All Urban Consumers (CPI-U). “Since ASCs use the same staff, services and supplies as HOPDs, it only makes sense to apply the same inflation rate for our yearly updates,” said Prentice.

“Under the final rule, ASCs will see, on average over all covered procedures, an effective update of 2.1 percent,” he added.

Other new policies in the final payment rule encourage the migration of device intensive procedures to ASCs and allow for several new cardiac procedures in the ASC setting. “These changes are positive and beneficial for ASCs and the patients they serve, and we are encouraged to see CMS adopting these policies,” said Prentice.

More specifically, CMS reduced the threshold definition of device intensive procedures in ASCs from 40 percent to 30 percent.

“So if the device portion of the overall procedure equals 30 percent or more of the total cost of the procedure in the HOPD setting, the total device cost will be included in the reimbursement rate when the procedure is performed in an ASC,” Prentice explained.

“This decision results in a net increase of 124 new device intensive procedures that ASCs can now afford to provide for Medicare beneficiaries for the first time,” he added. As a result, the approved list will expand from 153 to 277 device intensive procedures in 2019.

“This is a policy change we have been advocating for over the past several years to encourage migration of these procedures into ASCs,” said Prentice.

Accounting for Surgery-Like Procedures

According to Prentice, CMS also revised its definition of “surgery” to account for certain “surgery-like” procedures that are assigned codes outside the Current Procedural Terminology (CPT) surgical range.

“This change allowed CMS to add the 12 cardiac catheterization procedures that were included in the proposed rule to the ASC covered procedures list,” said Prentice. “Based on feedback from stakeholders, CMS also added five additional procedures that are often performed alongside those codes.”

There is also a provision in the final payment rule that addresses payment for non-opioid pain management therapy. Prentice says this is a result of President Donald Trump’s emphasis on responding to the opioid epidemic in America.

“Past payment policy served as an impediment to using non-opioids for post-surgical pain,” Prentice said. “This provision addresses our concerns by allowing ASCs to get paid for non-opioid pain relief drugs when used in a surgical procedure.”

Education is Crucial

Because “the devil is in the details” when it comes to Medicare quality reporting compliance, Prentice recommends that ASCs educate themselves thoroughly on the final 2019 payment rule.

ASCA has prepared a free webinar hosted by Throneberry and ASC Quality Collaboration Executive Director Donna Slosburg that answers common questions about the final payment rule. The webinar is now available on demand at https://www.ascassociation.org/educationevents/upcomingevents/webinars.

“I recommend that all ASCs listen to this webinar to make sure they are doing everything needed to comply,” said Prentice.