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How to Report ASC-20 Accurately

What you need to know about the COVID-19 Vaccination Coverage Among HCP measure

BY KARA NEWBURY | FEBRUARY 2022

In the 2022 OPPS/ASC final payment rule, regarding the ASC Quality Reporting (ASCQR) Program, the Centers for Medicare & Medicaid Services (CMS) finalized its proposal to “Adopt ASC-20: COVID-19 Vaccination Coverage Among HCP [Health Care Personnel] measure beginning with the CY 2024 payment determination.” For a new measure, this is an accelerated timeline, as CY 2024 payment determinations are impacted by data collected and reported in 2022.

Measure Specifications

The information in the Specifications Manual is limited, but the basics of the measure follow.

• ASCs will report ASC-20: COVID-19 Vaccination Coverage Among HCP data through the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) Healthcare Personnel Safety (HPS) Component. Surgery centers must pick at least one week each month for data collection to be submitted for a quarter at a time.
• Denominator: The number of HCP eligible to work in the ASC for at least one day during the self-selected week, excluding persons with contraindications to COVID-19 vaccination.
• Numerator: The cumulative number of HCP eligible to work in the ASC for at least one day during the self-selected week and who received a complete vaccination course against COVID-19 using a US Food & Drug Administration (FDA)-authorized or FDA-approved vaccine for COVID-19. A complete vaccination course is defined under the specific FDA authorization and may require multiple doses or regular revaccination.

NHSN Enrollment

Before data can be entered, a facility must have

1. an active NHSN account, and
2. an NHSN Facility Administrator (FA) with a current Secure Access Management Services (SAMS) security profile.

ASCs can enroll on the NHSN enrollment website, and use the CDC ASC enrollment checklist to enroll. If you are not sure whether you are enrolled, please start with this ASCA NHSN enrollment resource, which walks through the following scenarios:

1. facility has an active NHSN account and current NHSN FA
2. facility has an active NHSN account, but the SAMS profile is expired (not logged in to SAMS at least once per year) OR the NHSN FA is new
3. facility does not have an NHSN account or NHSN FA

If you have access but need to change the FA, please fill out the Change NHSN Facility Administrator form.

An ASC could still have access to NHSN, as this is where data was submitted for ASC-8: Influenza Vaccination Coverage Among Health Care Personnel (HCP). Although no longer required as part of the ASCQR Program, some states do still require influenza vaccination reporting through NHSN.

Data Collection and Reporting

Once enrolled, you can now enter data. As indicated above, you are required to select one week per month during which to report data. Even though we are past January, you can go back and enter data from previous months. Try to stay on a monthly reporting cycle because it would be easy to mix up data if you are reporting several months at a time.

Access and use the information on reporting on the Weekly HCP COVID-19 Vaccination page, especially the Instructions for Completion of the Weekly Healthcare Personnel COVID-19 Vaccination Cumulative Summary. CDC updated the FAQs on Reporting COVID-19 Vaccination Data in January.

In addition, an ASCA Board member took screenshots of the process as she entered her data for the first time and allowed ASCA to make available to our members her NHSN Instructions for COVID Reporting.

Data Submission Deadlines and Public Reporting

CMS plans to publicly report the most recent quarter of data available for each healthcare facility, and data will be available for preview by ASCs for 30 days prior to being made publicly available. The deadlines for quarterly data submissions follow.

If you have questions regarding NHSN training, enrollment and submission, email NHSN. ASCA has been in close contact with staff at the CDC and CMS, so if you have trouble reaching NHSN, please write Kara Newbury.