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ASCA, Ophthalmic Groups Meet With CMS Quality Reporting Staff

Participants primarily discuss ASC-11

BY KARA NEWBURY | APRIL 2023

On April 13, ASCA staff met with senior leadership at the Centers for Medicare & Medicaid Services (CMS) to discuss concerns with the ASC Quality Reporting (ASCQR) Program, primarily focusing on ASC-11: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery. ASCA invited the American Academy of Ophthalmology (AAO), the American Society of Cataract and Refractive Surgery (ASCRS) and the Outpatient Ophthalmic Surgery Society (OOSS) to participate on the call along with ASC Quality Collaboration (ASCQC) staff.

Michelle Schreiber, MD, deputy director of the Center for Clinical Standards and Quality (CCSQ) and director of the Quality Measurement and Value-based Incentives Group (QMVIG) for CMS, and Ron Kline, MD, chief medical officer of the QMVIG, represented CMS at the meeting.

ASC-11

ASCA and the ophthalmic societies have long opposed the inclusion of ASC-11 in the ASC Quality Reporting (ASCQR) Program. CMS first proposed the measure for inclusion in the ASCQR Program in its 2014 rulemaking. The measure has been voluntary since, but in 2022 rulemaking, CMS finalized its proposal for mandatory inclusion beginning in 2025. In 2023 rulemaking, CMS delayed future implementation at the time due to the COVID-19 public health emergency (PHE). As the PHE is set to end next month, ASCA staff thought it was worth discussing with CMS why this measure should be removed from the ASCQR Program independent of any ongoing burdens associated with COVID-19.

AAO staff provided an overview of the measure since it serves as the measure steward, meaning it is the organization that “owns” the measure and is responsible for maintaining it. ASC-11 assesses the percentage of patients aged 18 years and older who had cataract surgery and experienced improvement in visual function within 90 days following surgery. The results of this patient-reported outcome measure are based on patients’ completion of formal surveys of both preoperative and postoperative visual function. AAO staff explained that the measure was designed as a physician measure, not a facility-level measure, and that it is not actionable by ASCs.

This measure relies on the use of data obtained by the physician and recorded in the medical records housed in the physician office at two key points in time: (1) the patient’s visit(s) with the physician during which the evaluation, examination and decision regarding surgery were made, and (2) the patient’s visit(s) with the physician after surgery and during the postoperative 90-day global period. ASCs do not have access to these records. Asking ASCs to report this measure is administratively burdensome and not reflective of the attributes of the ASC facility or the actions of its staff during the patient’s time in the facility.

CMS is focused on coordination of care measures. ASCA and the ophthalmic society participants argued that the information required for this measure is not in the control of the ASC and that it would be a huge administrative burden for facilities, but the CMS staff did not seem persuaded.

ASC-16: Toxic Anterior Segment Syndrome

CMS is looking to expand upon the current ASCQR Program and ASCA needs to provide alternatives to measures that it does not think will improve patient care. During the meeting, ASCRS led the discussion regarding the potential inclusion of ASC-16: Toxic Anterior Segment Syndrome (TASS) in the ASCQR Program. The ASCQC is the measure steward for ASC-16, which was included in the 2018 proposed rule but never finalized for the ASCQR Program. This measure assesses the number of patients diagnosed with TASS within two days of undergoing anterior segment surgery in an ASC. The ASCQC developed this measure to fulfill a need to assess outcomes related to frequently performed ophthalmic surgeries, including cataract surgery, in ASCs. It also addresses care coordination. ASCA and the ophthalmic societies at the meeting all support future inclusion of this measure in the ASCQR Program.

The CMS staff thanked ASCA for raising this measure for future consideration.

ASC-20: COVID-19 Vaccination Coverage Among Health Care Personnel

ASCA also raised concerns with ASC-20: COVID-19 Vaccination Coverage Among Health Care Personnel (HCP), highlighting the significant administrative burden this measure has placed on healthcare facilities. CMS leadership indicated that COVID-19 and the safety of HCP remains a priority for the Biden administration. ASCA staff argued that since the vaccination status of patients and those who accompany them is unknown, knowing the percentage of HCP vaccinated within a facility is of limited value to patients.

Reporting Deadline Reminder and Resources

The next quarterly data submission deadline for ASC-20 is May 15, and covers the data collected in the fourth quarter of 2022, October 1 through December 31. Facilities must select one week per month on which to report to meet the quarterly submission requirement. May 15 also is the deadline by which ASCs must submit 2022 data via the Hospital Quality Reporting secure portal for ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients, ASC-13: Normothermia Outcome and ASC-14: Unplanned Anterior Vitrectomy. ASCs that fail to meet ASCQR Program requirements are subject to a 2 percent cut to their fee-for-service (FFS) Medicare reimbursements.

The ASCQR Program provides a Web-Based Measure Status Listing that allows facilities to check their data submission status for web-based measures in the program. Enter your ASC’s national provider identifier or CMS certification number in the ASC Facility and CCN Lookup section to see your facility’s submission status. ASCs that fail to meet ASCQR Program requirements are subject to a 2 percent cut to their FFS Medicare reimbursements.

ASCA has resources available to help, starting with the main Quality Reporting webpage. To ensure you are ready for compliance in 2023, the How to Meet Medicare’s 2023 ASC Quality Reporting (ASCQR) Program Requirements resource page takes you through the measures that remain in the program for 2023 and what you need to do to avoid penalties in 2024. Additional resources, including the ASCQR Program Specifications Manual, are available on the ASCQR Program website.

Write Kara Newbury with any questions.