Ambulatory Surgical Center Quality Reporting (ASCQR) Program

Ambulatory Surgical Center Quality Reporting Program (CMS-10530)

CMS-10530.ASC Manual_v6 0a_Full (with Exp and Control No)

Ambulatory Surgical Center Quality Reporting (ASCQR) Program

OMB: 0938-1270

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Ambulatory Surgical Center Quality Reporting
Specifications Manual
Version 6.0a
Encounter Dates: 01-01-17 (1Q17) through 12-31-17 (4Q17)
OMB # 0938-1270 Expiration Date:X/X/XXXX

Ambulatory Surgical Center Quality Reporting Specifications Manual
Release Notes Version: 6.0
Release Notes Completed: June 22, 2016
Guidelines for Using Release Notes
These Release Notes provide modifications to the Ambulatory Surgical Center Quality Reporting (ASCQR)
Specifications Manual. They are provided as a reference tool and are not intended to be used as program
abstraction tools. Please refer to the ASCQR Specifications Manual for the complete and current technical
specification and abstraction information.
The notes are organized to follow the order of the Table of Contents. Within each topic section, a row
represents a change that begins with general changes and is followed by data elements in alphabetical order.
The implementation date is 01/01/2017, unless otherwise specified. The row headings are described below:


Impacts – Used to identify which portion(s) of the Manual Section is impacted by the change listed.
Examples are Measure Information Forms, Quality-Data Coding and Sampling Specifications, or
Appendix A.



Rationale – Provided for the change being made.



Description of Changes – Used to identify the section within the document where the change occurs.
(e.g., Definitions, Numerator, and Denominator).

ASCQR Specifications Manual
Encounter dates 01-01-17 (1Q17) through 12-31-17 (4Q17) v6.0
CPT® only copyright 2016 American Medical Association. All rights reserved.

ASC Release Notes version 6.0
The notes in the tables below are organized to follow the Table of Contents in the Specifications Manual.
Table of Contents
No changes in this section.
Acknowledgement
Impacts: N/A
Rationale: To update the CPT® copyright year
Description of Change(s):
Change CPT® only copyright 2015 American Medical Association. All rights reserved.
To CPT® only copyright 2016 American Medical Association. All rights reserved.
Program Background
No changes in this section.
Using the Manual
No changes in this section.
Section 1: Measure Information Form Introduction
Impacts: N/A
Rationale: To align the ASCQR Specifications Manual with other Quality Reporting Program Specifications
Manuals
Description of Change(s):
Remove Reporting Mechanism, Reporting Period, and Reporting Required By overviews in their entirety
Measure Information Forms
Impacts: ASC-1, ASC-2, ASC-3, ASC-4, ASC-5, ASC-12
Rationale: To align the ASCQR Specifications Manual with other Quality Reporting Program Specifications
Manuals
Description of Change(s):
Reporting Mechanism, Reporting Period, Reporting Required By
Remove each section in its entirety

ASCQR Specifications Manual
Encounter dates 01-01-17 (1Q17) through 12-31-17 (4Q17) v6.0
CPT® only copyright 2016 American Medical Association. All rights reserved.

ASC Release Notes version 6.0
______________________________________________________________________________________
Impacts: ASC-6, ASC-7, ASC-8, ASC-9, ASC-10, ASC-11
Rationale: To align the ASCQR Specifications Manual with other Quality Reporting Program Specifications
Manuals
Description of Change(s):
Reporting Mechanism, Reporting Required By
Remove each section in its entirety
______________________________________________________________________________________
Impacts: ASC-6
Rationale: To align the ASCQR Specifications Manual with other Quality Reporting Program Specifications
Manuals
Description of Change(s):
Annual Data Submission Period
Add Data entry will be achieved through the secure side of QualityNet.org via an online tool available to
authorized users.
______________________________________________________________________________________
Impacts: ASC-7
Rationale: To align the ASCQR Specifications Manual with other Quality Reporting Program Specifications
Manuals
Description of Change(s):
Annual Data Submission Period
Add Data entry will be achieved through the secure side of QualityNet.org via an online tool available to
authorized users.
Table 2
Remove Current table
Add The Categories and HCPCS will be updated at the end of CY 2017.
______________________________________________________________________________________
Impacts: ASC-9
Rationale: To allow for exclusion of patients when their age is documented as the reason the physician did
not recommend a follow-up colonoscopy and to align the ASCQR Specifications Manual with other Quality
Reporting Program Specifications Manuals.
Description of Change(s):
Add the word Statement to the Numerator and Denominator descriptions
Denominator Exclusions
ASCQR Specifications Manual
Encounter dates 01-01-17 (1Q17) through 12-31-17 (4Q17) v6.0
CPT® only copyright 2016 American Medical Association. All rights reserved.

ASC Release Notes version 6.0
Add Documentation indicating no follow-up colonoscopy is needed or recommended is only acceptable if
the patient’s age is documented as the reason.
Annual Data Submission Period
Add Data entry will be achieved through the secure side of QualityNet.org via an online tool available to
authorized users.
______________________________________________________________________________________
Impacts: ASC-10
Rationale: To align the ASCQR Specifications Manual with other Quality Reporting Program Specifications
Manuals
Description of Change(s):
Add the word Statement to the Numerator and Denominator descriptions
Annual Data Submission Period
Add Data entry will be achieved through the secure side of QualityNet.org via an online tool available to
authorized users.
______________________________________________________________________________________
Impacts: ASC-11
Rationale: To align the ASCQR Specifications Manual with other Quality Reporting Program Specifications
Manuals
Description of Change(s):
Add the word Statement to the Numerator and Denominator descriptions
Annual Data Submission Period
Add Data entry will be achieved through the secure side of QualityNet.org via an online tool available to
authorized users.
______________________________________________________________________________________
Impacts: ASC-12
Rationale: These changes reflect the removal of references to ICD-9 codes, since by the CY2017
performance period, the measure will not include them (even in one-year lookback period.)
Description of Change(s):
1. Cohort Exclusions
Change the title of Table 1 from:
 “Inflammatory Bowel Disease (IBD) ICD-9 and ICD-10-CM Diagnosis Codes
to
 “Inflammatory Bowel Disease (IBD) ICD-10-CM Diagnosis Codes
2. Cohort Exclusions

ASCQR Specifications Manual
Encounter dates 01-01-17 (1Q17) through 12-31-17 (4Q17) v6.0
CPT® only copyright 2016 American Medical Association. All rights reserved.

ASC Release Notes version 6.0
Remove the first two columns of Table 1 containing ICD-9 codes and descriptions (not marked as change in
MIF mockup)
3. Cohort Exclusions
Add a note under Table 1 that reads:
 “Note: For the ICD-9 codes relevant to the calculation of the measure for the CY2016 period, refer to
v5.1 of the manual.”
4. Cohort Exclusions
Change the title of Table 2 from:
 “Diverticulitis ICD-9 and ICD-10-CM Diagnosis Codes
to
 “Diverticulitis ICD-10-CM Diagnosis Codes
5. Cohort Exclusions
 Remove the first two columns of Table 2 (not marked as change in MIF mockup)
6. Cohort Exclusions
Add a note under Table 2 that reads:
 “Note: for the ICD-9 codes relevant to the calculation of the measure for the CY2016 period, refer to
v5.1 of the manual.”
7. Risk Adjustment
Change:
 “The measure defines comorbidity variables using condition categories (CCs), which are clinically
meaningful groupings of more than 15,000 ICD-9 diagnosis codes.”
to
 “The measure defines comorbidity variables using condition categories (CCs), which are clinically
meaningful groupings of the many thousands of ICD-10-CM diagnosis codes.”

Section 2: Quality-Data Coding & Sampling Specifications
No changes in this section.
Appendix A: Glossary of Terms
No changes in this section.

ASCQR Specifications Manual
Encounter dates 01-01-17 (1Q17) through 12-31-17 (4Q17) v6.0
CPT® only copyright 2016 American Medical Association. All rights reserved.

Ambulatory Surgical Center Quality Reporting Specifications Manual
Release Notes Version: 6.0a
Release Notes Completed: December 15, 2016
Guidelines for Using Release Notes
These Release Notes provide modifications to the Ambulatory Surgical Center Quality Reporting (ASCQR)
Specifications Manual. They are provided as a reference tool and are not intended to be used as program
abstraction tools. Please refer to the ASCQR Specifications Manual for the complete and current technical
specification and abstraction information.
The notes are organized to follow the order of the Table of Contents. Within each topic section, a row
represents a change that begins with general changes and is followed by data elements in alphabetical order.
The implementation date is 01/01/2017, unless otherwise specified. The row headings are described below:




Rationale – Provided for the change being made.



Description of Changes – Used to identify the section within the document where the change occurs.
(e.g., Definitions, Numerator, and Denominator).

ASCQR Specifications Manual
Encounter dates 01-01-17 (1Q17) through 12-31-17 (4Q17) v6.0a
CPT® only copyright 2017 American Medical Association. All rights reserved.

ASC Release Notes version 6.0a
The notes in the tables below are organized to follow the Table of Contents in the Specifications Manual.
Table of Contents
Impacts: Added section to Table of Contents
Rationale: To include the Preview Section which will display new measure information.
Description of Change(s):
Add
Appendix B: Preview Section
Acknowledgement
No changes in this section.
Program Background and Requirements
Impacts: This section has been updated to include Program Requirements
Rationale: To provide additional information regarding the background and requirements of the ASCQR
program
Description of Change(s):
Program Requirements
Add
ASCs that do not meet program requirements, which include reporting of quality measure data for the
ASCQR Program, may receive a two percent reduction in their ASC payment update. ASCQR Program
requirements apply to all entities subject to the ASC Fee Schedule (ASCFS). The definition of an ASC can
be found in the Claims Processing Manual, Chapter 14, Section 10.1, located at (www.cms.hhs.gov).
Data Collection and Submission
Data for claims-based measures included in this specifications manual are captured from Medicare Part B
fee-for-service (FFS) claims submitted by the ASC during required reporting periods. Medicare Part B FFS
patients include Medicare Railroad Retirement Board patients and Medicare Secondary payer patients.
Medicare Advantage patients are not included for reporting purposes. For claims-based measures, the
reporting period refers to the dates of service not date of submission. For example, if a service was provided
on December 30, 2016, with claim submission on January 1, 2017, this claim would be included in the 2018
payment determination.
Claims-Based Measures
ASCs are to submit information on the five claims-based measures using Quality Data Codes (QDCs)
entered on their claims submitted using the CMS-1500 or associated electronic dataset. QDCs are specified
CPT Category II codes or Level II G-codes that describe the clinical action evaluated by the measure.
Clinical actions can apply to more than one condition and, therefore, can also apply to more than one
measure. Facilities should review all reporting instructions carefully.

ASCQR Specifications Manual
Encounter dates 01-01-17 (1Q17) through 12-31-17 (4Q17) v6.0a
CPT® only copyright 2016 American Medical Association. All rights reserved.

ASC Release Notes version 6.0a
The appropriate QDC(s) are to be reported for all Medicare Part B FFS patients in addition to any codes that
would be standard for billing purposes (e.g., the ICD-10-CM diagnosis and Current Procedural Terminology
(CPT) codes, Healthcare Common Procedure Coding System (HCPCS) Level II and CPT Category III codes
for the services performed) on the ASC claim for the encounter.
Data completeness will be calculated by comparing the number of claims meeting measure specifications
with the appropriate QDCs to the number of claims that would meet measure specifications without the
appropriate QDCs on the submitted claim.
Measures Submitted via a Web-Based Tool
Data for ASC-6, ASC-7, ASC-9, ASC-10, and ASC-11 (ASC-11 is a voluntary measure) are to be submitted
using a web-based tool located on the QualityNet Secure Portal at www.QualityNet.org.
Data for ASC-8 Influenza Vaccination Coverage among Healthcare Personnel will be submitted through the
National Healthcare Safety Network (NHSN) at http://www.cdc.gov/nhsn.
Please refer to www.QualityNet.org for data submission deadlines.
240 or Fewer Rule
CMS determined that some ASCs have relatively small numbers of Medicare claims and instituted a claims
threshold for ASCs with fewer than 240 Medicare claims (primary plus secondary payer) per year. For
example, an ASC with fewer than 240 Medicare claims in CY 2016 (for the CY 2018 payment determination
year) would not be required to participate in the ASCQR Program in CY 2017 (for the CY 2019 payment
determination year).
Public Reporting
The Secretary of Health and Human Services must establish procedures to make data collected under the
ASC Quality Reporting Program publicly available and to supply facilities the opportunity to review their
data prior to publication. Details on the ability to withdraw and not have data publicly reported, the
extraordinary circumstance extensions or exemptions request process, and the reconsideration request
process were finalized in the FY 2013 IPPS/LTCH final rule.

Using the Manual
The Using the Manual section has been removed from this manual.
Section 1: Measure Information Form Introduction
Impacts: Measure Information Form Introduction and Measure Information Forms ASC-6, ASC-7, ASC-9,
ASC-10, and ASC-11,
Rationale: To align the manual with terminology found in the Final Rule
Description of Change(s):
Quality Reporting Option:
Change
Web-based Measure
To
Measures submitted via a web-based tool

ASCQR Specifications Manual
Encounter dates 01-01-17 (1Q17) through 12-31-17 (4Q17) v6.0a
CPT® only copyright 2016 American Medical Association. All rights reserved.

ASC Release Notes version 6.0a
Measure Information Forms
Impacts: ASC-7
Rationale: To inform providers of pending updates to the Volume data measure.
Description of Change(s):
Add
*Please note the categories and HCPCS for ASC-7: ASC Facility Volume Data on Selected ASC Surgical
Procedures will be populated here in November 2017 for encounters from 01-01-17 through 12-31-17.]

Impacts: ASC-8
Rationale: To add clarification to the voluntary category of contract personnel.
Description of Change(s):
Definition for Healthcare Personnel (HCP)
After
Facilities must report vaccination data for three categories of HCP: employees on payroll; licensed
independent practitioners (who are physicians, advanced practice nurses, and physician assistants affiliated
with the hospital and not on payroll); and students, trainees, and volunteers aged 18 or older.
Add
Reporting data on the optional, other contract personnel category is not required at this time.

Impacts: ASC-10
Rationale: To remove ICD-10-CM Code
Description of Change(s):
Denominator Criteria (Eligible Cases)
Remove
Code Z85.038 from Diagnosis for history of colonic polyp(s)
______________________________________________________________________________________
Impacts: ASC-12
Rationale: To reflect clarifications to the ICD-10 codes listed in Table 1 for Inflammatory Bowel Disease
(IBD). These do not represent code changes but are changes to the wildcard used to represent ranges of codes
and some labels, as well as removing duplicate ICD-10 codes.
Description of Change(s):
Cohort Exclusions
Change
Table 1
 Changed the use of the wildcard ‘X’ at end of ICD-10 codes to ‘*’ for clarity (since ‘X’ could be
confused with part of code)
ASCQR Specifications Manual
Encounter dates 01-01-17 (1Q17) through 12-31-17 (4Q17) v6.0a
CPT® only copyright 2016 American Medical Association. All rights reserved.

ASC Release Notes version 6.0a



Removed ‘without complications’ from some of the ICD-10 code labels
Removed two duplicate rows (for codes 51.80* and 51.8*)

Section 2: Quality-Data Coding & Sampling Specifications
No changes in this section.
Appendix A: Glossary of Terms
No changes in this section.
Appendix B: Preview Section
Impacts: The Preview Section displays new measure information.
Rationale: To provide new measure information finalized for the CY 2020 payment determination. The
measures identified in this section are not currently collected.
Description of Change(s):
Add
ASC-13: Normothermia Outcome
ASC-14: Unplanned Anterior Vitrectomy
ASC-15a-e: Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems
(OAS CAHPS) Survey Measures
______________________________________________________________________________________

ASCQR Specifications Manual
Encounter dates 01-01-17 (1Q17) through 12-31-17 (4Q17) v6.0a
CPT® only copyright 2016 American Medical Association. All rights reserved.

M aterial ins ide brackets ([and]) is new to this Specifications M anual vers ion.

Table of Contents
Acknowledgement ................................................................................................................................................. ii
Program Background and Requirements ......................................................................................................... iii
Section 1: Measure Information Form Introduction ...................................................................................... 1-1
Measure Information Forms
ASC-1: Patient Burn ............................................................................................................................................ 1-3
ASC-2: Patient Fall .............................................................................................................................................. 1-6
ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant ....................................... 1-8
ASC-4: All Cause Hospital Transfer/Admission ............................................................................................... 1-10
ASC-5: Prophylactic Intravenous (IV) Antibiotic Timing ................................................................................ 1-12
ASC-6: Safe Surgery Checklist Use .................................................................................................................. 1-15
ASC-7: ASC Facility Volume Data on Selected ASC Surgical Procedures ..................................................... 1-16
ASC-8: Influenza Vaccination Coverage among Healthcare Personnel............................................................ 1-17
ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy
in Average Risk Patients ...................................................................................................................... 1-18
ASC-10: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of
Adenomatous Polyps – Avoidance of Inappropriate Use .................................................................. 1-20
ASC-11: Cataracts – Improvement in Patient’s Visual Function within 90 Days Following
Cataract Surgery................................................................................................................................. 1-22
ASC-12: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy....................... 1-23
Section 2: Quality-Data Coding & Sampling Specifications ........................................................................ 2-29
Appendix A: Glossary of Terms .................................................................................................................... A-30
Appendix B: Preview Section .......................................................................................................................... P-31

ASCQR Specifications Manual
Encounter dates 01-01-17 (1Q17) through 12-31-17 (4Q17) v6.0a
CPT® only copyright 2016 American Medical Association. All rights reserved.

M aterial ins ide brackets ([and]) is new to this Specifications M anual vers ion.

Acknowledgement
The Ambulatory Surgical Center Quality Reporting (ASCQR) Specifications Manual was developed by the
Centers for Medicare & Medicaid Services (CMS) to provide a uniform set of quality measures to be
implemented in ASC settings. The primary purpose of these measures is to promote high quality care for
patients receiving services in ASC settings.
No royalty or use fee is required for copying or reprinting this manual, but the following are required as a
condition of usage: 1) disclosure that the ASCQR Specifications Manual is periodically updated, and that the
version being copied or reprinted may not be up-to-date when used unless the copier or printer has verified
the version to be up-to-date and affirms that, and 2) users participating in the Ambulatory Surgical Center
Quality Reporting Program (ASCQR Program) are required to update their software and associated
documentation based on the published manual production timelines.
Example Acknowledgement: The ASCQR Specifications Manual [Version xx, Month, Year] is periodically
updated by the Centers for Medicare & Medicaid Services. Users of the ASCQR Specifications Manual must
update their software and associated documentation based on the published manual production timelines.
CPT® only copyright 2016 American Medical Association. All rights reserved.
CPT® is a registered trademark of the American Medical Association.

Applicable FARS\DFARS Restrictions Apply to Government Use.
Fee Schedules, relative value units, conversion factors and/or related components are not assigned by the
AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or
indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained
or not contained herein.
The International Classification of Diseases, 11th Revision, Clinical Modification (ICD-10-CM) is published
by the United States Government. A CD-ROM, which may be purchased through the Government Printing
Office, is the only official Federal government version of the ICD-10-CM. ICD-10-CM is an official Health
Insurance Portability and Accountability Act standard.
IMPORTANT SUBMISSION ALERT!!
At this time, for submission of the Ambulatory Surgical Center measures to CMS under the
Ambulatory Surgical Center Quality Reporting Program (ASCQR Program), files must meet the
specifications in this CMS manual only. Otherwise, the files will be rejected as not meeting CMS
quality data submission requirements for receiving the full payment update.

ASCQR Specifications Manual
Encounter dates 01-01-17 (1Q17) through 12-31-17 (4Q17) v6.0a
CPT® only copyright 2016 American Medical Association. All rights reserved.

Material inside brackets ([and]) is new to this Specificatio ns Manual version.

Program Background and Requirements
CMS Quality Initiatives
Background
In November 2001, Health & Human Services’ (HHS) Secretary Tommy G. Thompson announced The
Quality Initiative, his commitment to assure quality healthcare for all Americans through published
consumer information coupled with healthcare quality improvement support through Medicare’s Quality
Improvement Organizations (QIOs). The Quality Initiative was launched nationally in 2002 as the Nursing
Home Quality Initiative (NHQI) and expanded in 2003 with the Home Health Quality Initiative (HHQI) and
the Hospital Quality Initiative (HQI). These initiatives are part of a comprehensive look at quality of care
that includes hospitals, nursing homes, home health agencies, and physician offices. These efforts have
continued to expand under subsequent Secretaries through support and expansion of activities to support
healthcare transparency and value-driven healthcare.
The Medicare Improvements and Extension Act under Division B of Title I of the Tax Relief and Health
Care Act (MIEA-TRHCA) of 2006 (Pub. L. 109-432), enacted on December 20, 2006, made changes in the
Outpatient Prospective Payment Systems (OPPS). The Centers for Medicare & Medicaid Services (CMS)
became statutorily required in the Calendar Year (CY) 2008 OPPS/ASC Final Rule to have a program under
which ASCs will report data on the quality of ASC care using standardized measures to receive the full
annual update to the ASC payment rate. The program established under the CY 2012 OPPS/ASC Final Rule
with Comment Period (CMS-1525-FC) and supported by this manual is the Ambulatory Surgical Center
Quality Reporting Program (ASCQR Program). The measures described in this manual will expand as
additional priority areas for quality improvements in ASC settings are identified and will be designed to
evaluate the diversity of services and clinical topics provided to adult patients in ASC settings.
The claims-based measures ASC-1 through ASC-5, adopted by CMS for the ASCQR Program, were
originally developed by the ASC Quality Collaboration and are the intellectual property of the ASC Quality
Collaboration. Additional information about the ASC quality measures endorsed by the National Quality
Forum (NQF) is available in the ASC Quality Collaboration Implementation Guide (www.ascquality.org).
Objective
The ASCQR Program uses a variety of tools to stimulate and support a significant improvement in the
quality of ASC care. This initiative aims to refine and standardize ASC data collection, data transmission,
and performance measures in order to construct a robust, prioritized, and standard quality outpatient measure
set for ASCs. The goal is for all private and public purchasers, oversight and accrediting entities, and payers
and providers of ASC care to use these same measures in their national public reporting activities. Quality
improvement support, collaborations, standardization, and assuring compliance with Medicare Conditions of
Participation (CoPs) are important additional tools in achieving this objective.
Program Requirements
ASCs that do not meet program requirements, which include reporting of quality measure data for the
ASCQR Program, may receive a two percent reduction in their ASC payment update. ASCQR Program
requirements apply to all entities subject to the ASC Fee Schedule (ASCFS). The definition of an ASC can
be found in the Claims Processing Manual, Chapter 14, Section 10.1, located at (www.cms.hhs.gov).
[

]

ASCQR Specifications Manual
Encounter dates 01-01-17 (1Q17) through 12-31-17 (4Q17) v6.0a
CPT® only copyright 2016 American Medical Association. All rights reserved.

iii

Data Collection and Submission
Data for claims-based measures included in this specifications manual are captured from Medicare Part B
fee-for-service (FFS) claims submitted by the ASC during required reporting periods. Medicare Part B FFS
patients include Medicare Railroad Retirement Board patients and Medicare Secondary payer patients.
Medicare Advantage patients are not included for reporting purposes. For claims-based measures, the
reporting period refers to the dates of service not date of submission. For example, if a service was provided
on December 30, 2016, with claim submission on January 1, 2017, this claim would be included in the 2018
payment determination.]
[

Claims-Based Measures
[ASCs are to submit information on the five claims-based measures using Quality Data Codes (QDCs)
entered on their claims submitted using the CMS-1500 or associated electronic dataset. QDCs are specified
CPT Category II codes or Level II G-codes that describe the clinical action evaluated by the measure.
Clinical actions can apply to more than one condition and, therefore, can also apply to more than one
measure. Facilities should review all reporting instructions carefully.]
The appropriate QDC(s) are to be reported for all Medicare Part B FFS patients in addition to any codes that
[would be standard for billing purposes (e.g., the ICD-10-CM diagnosis and Current Procedural Terminology
(CPT) codes, Healthcare Common Procedure Coding System (HCPCS) Level II and CPT Category III codes
for the services performed) on the ASC claim for the encounter.]

Data completeness will be calculated by comparing the number of claims meeting measure specifications
[with the appropriate QDCs to the number of claims that would meet measure specifications without the
appropriate QDCs on the submitted claim.]
Measures Submitted via a Web-Based Tool
[Data for ASC-6, ASC-7, ASC-9, ASC-10, and ASC-11 (ASC-11 is a voluntary measure) are to be submitted
using a web-based tool located on the QualityNet Secure Portal at www.QualityNet.org.]
Data for ASC-8 Influenza Vaccination Coverage among Healthcare Personnel will be submitted through the
[National Healthcare Safety Network (NHSN) at http://www.cdc.gov/nhsn.]
[

Please refer to www.QualityNet.org for data submission deadlines.]

240 or Fewer Rule
[CMS determined that some ASCs have relatively small numbers of Medicare claims and instituted a claims
threshold for ASCs with fewer than 240 Medicare claims (primary plus secondary payer) per year. For
example, an ASC with fewer than 240 Medicare claims in CY 2016 (for the CY 2018 payment determination
year) would not be required to participate in the ASCQR Program in CY 2017 (for the CY 2019 payment
determination year).]
Public Reporting
[The Secretary of Health and Human Services must establish procedures to make data collected under the
ASC Quality Reporting Program publicly available and to supply facilities the opportunity to review their
data prior to publication. Details on the ability to withdraw and not have data publicly reported, the
extraordinary circumstance extensions or exemptions request process, and the reconsideration request
process were finalized in the FY 2013 IPPS/LTCH final rule.]

ASCQR Specifications Manual
Encounter dates 01-01-17 (1Q17) through 12-31-17 (4Q17) v6.0a
CPT® only copyright 2016 American Medical Association. All rights reserved.

Related National Activities
National Quality Forum (NQF)
The NQF has approved a set of national voluntary consensus standards for measuring the quality of hospital
care. These measures will permit consumers, providers, purchasers, and quality improvement professionals
to evaluate and compare the quality of care in a variety of healthcare settings across the nation by using a
standard set of measures. Measures that are endorsed by NQF are denoted as such on the measure
information forms.
National Quality Measures Clearinghouse
The National Quality Measures Clearinghouse (NQMC), sponsored by the Agency for Healthcare Research
and Quality (AHRQ), an agency of the U.S. Department of HHS, has included both CMS and Joint
Commission measures in the public database for evidence-based quality measures and measure sets. NQMC
is sponsored by AHRQ to promote widespread access to quality measures by the healthcare community and
other interested individuals.
Measures Management System
The Measures Management System (MMS) is a set of processes and decision criteria used by CMS to
oversee the development, implementation, and maintenance of healthcare quality measures. CMS recognizes
the need for quality measures of the highest caliber, maintained throughout their life cycle to ensure they
retain the highest level of scientific soundness, importance, feasibility, and usability. Through the use of a
standardized process with broadly recognized criteria, the MMS ensures that CMS will have a coherent,
transparent system for measuring the quality of care delivered to its beneficiaries.

ASCQR Specifications Manual
Encounter dates 01-01-17 (1Q17) through 12-31-17 (4Q17) v6.0a
CPT® only copyright 2016 American Medical Association. All rights reserved.

Material inside brackets ([and]) is new to this Specificatio ns Manual version.

Measure Information Form Introduction
Measure Information Form (MIF) Format
Measure Title – The specific national ASC quality measure (e.g., Patient Burn, Patient Fall, All Cause
Hospital Transfer/Admission).
Measure ID # – A unique alphanumeric identifier assigned to the measure. Information associated with a
measure is identified by this alphanumeric number (i.e., ASC-1, ASC-2, ASC-3, etc.).
Quality Reporting Option – Indicates what is being evaluated by the measure.
 Outcome: A measure that indicates the result of performance (or non-performance) of a function(s) or
process(es).
 Process: A measure used to assess a goal-directed, interrelated series of actions, events, mechanisms, or
steps, such as a measure of performance that describes what is done to, for, or by patients, as in
performance of a procedure.
 Measures Submitted via a Web-based Tool: A measure used to assess a goal-directed, interrelated
series of actions, events, mechanisms, or steps with data entry achieved through the secure side of
QualityNet.org via an online tool available to authorized users.
[

]

Description – A brief explanation of the measure’s focus, such as the activity or the area on which the
measure centers attention (e.g., the number of admissions (patients) who are transferred or admitted to a
hospital upon discharge from the ASC).
Denominator Statement – Represents the population evaluated by the performance measure.
 Included Population in Denominator: Specific information describing the population(s)
comprising the denominator, not contained in the denominator statement, or not applicable.
 Excluded Population in Denominator: Specific information describing the population(s)
that should not be included in the denominator, or none.
Numerator Statement – Represents the portion of the denominator that satisfies the conditions of the
performance measure.
 Included Population in Numerator: Specific information describing the population(s) comprising the
numerator, not contained in the numerator statement, or not applicable.
 Excluded Population in Numerator: Specific information describing the population(s) that should not
be included in the numerator, or none.
Numerator Quality-Data Coding Options for Reporting – A list and definition of the QDC(s) (currently
all are G-codes) used to report required information for the measure.
Data Sources – The documents that typically contain the information needed to determine the numerator and
denominator.
Definitions – Specific definitions for the terms included in the numerator and denominator statements.
Selection Basis – The reason for performing a specified process to improve the quality of care outcome. This
may include specific literature references, evidence-based information, expert consensus, etc.
Clinical Recommendation Statements – Supporting literature statements for the specified quality of care
measure.
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Selected References – Specific literature references that are used to support the importance of the
performance measure.

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Material inside brackets ([and]) is new to this Specifications Manual version.

Measure Information Form
Measure Title: Patient Burn
Measure ID #: ASC-1
Quality Reporting Option: Claims-based outcome measure
Description: The number of admissions (patients) who experience a burn prior to discharge from the ASC
Denominator: All ASC admissions
Inclusions: All ASC admissions
Exclusions: None
Numerator: ASC admissions experiencing a burn prior to discharge
Inclusions: ASC admissions experiencing a burn prior to discharge
Exclusions: None
Numerator Quality-Data Coding Options for Reporting:
 G8908: Patient documented to have received a burn prior to discharge
 G8909: Patient documented not to have received a burn prior to discharge
 G8907: Patient documented not to have experienced any of the following events: a burn prior to
discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong procedure, or wrong
implant event; or a hospital transfer or hospital admission upon discharge from the facility
Note: If using code G8908 or G8909, do not use code G8907.
Definitions:
 Admission – Completion of registration upon entry into the facility
 Burn – Unintended tissue injury caused by any of the six recognized mechanisms: scalds, contact, fire,
chemical, electrical, or radiation (e.g., warming devices, prep solutions, electrosurgical unit, or laser)
 Discharge – Occurs when the patient leaves the confines of the ASC
Selection Basis:
There are numerous case reports in the literature regarding patient burns in the surgical and procedural
setting. The diversity of the causative agents underscores the multitude of potential risks that must be
properly mitigated to avoid patient burns.
The literature on burns suggests that electrosurgical burns are most common. A recent publication from the
ECRI Institute (www.ecri.org) highlights the increased risk of burns with newer surgical devices that apply
higher currents at longer activation times. Although electrical burns are most prevalent, other mechanisms of
burn injury are frequently reported in case studies and case series. These include chemical and thermal burns.
Surgical fires are rare; however, their consequences can be grave, killing or seriously injuring patients and
surgical staff. The risk of surgical fire is present whenever and wherever surgery is performed, whether in an
operating room (OR), a physician’s office, or an outpatient clinic.

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Recognizing the diversity of mechanisms by which a patient could sustain an unintentional burn in the ASC
setting, the definition of burn is broad, encompassing all six recognized means by which a burn can occur –
scalds, contact, fire, chemical, electrical, or radiation. This will allow stakeholders to develop a better
understanding of the incidence of these events and further refine means to ensure prevention.
Clinical Recommendation Statements:
The risk of burns related to laser use can be reduced by adherence to the guidelines published by the
American National Standards Institute (ANSI) for safe use of these devices in the health care setting.
Similarly, the risk of burns related to the use of electrosurgical devices can be reduced by following the
electrosurgery checklist published by ECRI Institute.
The risk of surgical fires can be reduced by minimizing ignition, oxidizer, and fuel risks (the “classic
triangle”). The American Society of Anesthesiologist’s Practice Advisory for the Prevention and
Management of Operating Room Fires seeks to prevent the occurrence of OR fires, reduce adverse outcomes
associated with OR fires, and identify the elements of a fire response protocol. These guidelines are available
at: https://asahq.org/quality-and-practice-management/standards-and-guidelines.
Guidance for the prevention of surgical fire has also been published by the Association of Perioperative
Registered Nurses (AORN).
Additional information and resources, such as sample data collection forms and frequently asked questions
(FAQs) about the measures, can be found on the ASC Quality Collaboration website at www.ascquality.org.
Selected References:
 American National Standards Institute (ANSI) Z136.3 (2005) – Safe Use of Lasers in Health Care
Facilities, 2005 Revision.
 American Society of Anesthesiologists Task Force on Operating Room Fires, Caplan RA, Barker SJ, et
al. Practice advisory for the prevention and management of operating room fires. Anesthesiology 2008
May; 108(5):786-801.
 Anesthesia Patient Safety Foundation (APSF). Prevention and management of surgical fires [video].
February 2010. http://www.apsf.org/resources_video.php.
 ECRI Institute. New clinical guide to surgical fire prevention: patients can catch fire—here’s how to
keep them safer [guidance article]. Health Devices 2009 Oct; 38(10):314-32.
 ECRI Institute. Electrosurgery Checklist. http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8271.
 National Fire Protection Association (NFPA). NFPA 99: standard for health care facilities. Quincy (MA).
NFPA; 2005.
 Association of Operating Room Nurses (AORN). AORN Guidance Statement: Fire Prevention in the
Operating Room in Standards, Recommended Practices, and Guidelines. Denver, CO: AORN, 2006.
 AORN. Fire safety Tool Kit. 2015. http://www.aorn.org/guidelines/clinical-resources/tool-kits/firesafety-tool-kit.
 National Quality Forum. Serious Reportable Events in Healthcare 2006 Update. Washington, FC: NQF,
2007.
 Joint Commission. Joint Commission Sentinel Event Alert. Issue 12, February 4, 2000. Operative and
Postoperative Complications: Lessons for the Future. Chicago, IL.
 Tucker R. Laparoscopic electrosurgical injuries: survey results and their implications. Surg Laparosc
Endosc. 1995; 5(4):311- 7.
 ECRI. Higher currents, greater risks: preventing patient burns at the return-electrode site during highcurrent electrosurgical procedures. Health Devices. 2005; 34(8):273-9.
 Demir E, O’Dey D, and Pallua N. Accidental burns during surgery. J Burn Care Res. 2006; 27(6):895900.
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




Cheney F, Posner K, Caplan R, and Gild W. Burns from warming devices in anesthesia. A closed claims
analysis. Anesthesiology. 1994; 80(4):806-10.
Barker S and Polson J. Fire in the operating room: a case report and laboratory study. Anesth Anal. 2001;
93:960-965.
ECRI. Devastation of patient fires. Health Devices. 1992; 21:3-39.
Bhananker S, Posner K, Cheney F, Caplan R, Lee L, and Domino K. Injury and liability associated with
monitored anesthesia care: a closed claims analysis. Anesthesiology. 2006; 104(2):228-34.

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Measure Information Form
Measure Title: Patient Fall
Measure ID #: ASC-2
Quality Reporting Option: Claims-based outcome measure
Description: The number of admissions (patients) who experience a fall within the ASC
Denominator: All ASC admissions
Inclusions: All ASC admissions
Exclusions: None
Numerator: ASC admissions experiencing a fall within the confines of the ASC
Inclusions: ASC admissions experiencing a fall within the confines of the ASC
Exclusions: ASC admissions experiencing a fall outside the ASC
Numerator Quality-Data Coding Options for Reporting:
 G8910: Patient documented to have experienced a fall within the ASC
 G8911: Patient documented not to have experienced a fall within the ASC
 G8907: Patient documented not to have experienced any of the following events: a burn prior to
discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong procedure, or wrong
implant event; or a hospital transfer or hospital admission upon discharge from the facility
Note: If using code G8910 or G8911, do not use code G8907.
Definitions:
 Admission – Completion of registration upon entry into the facility
 Fall – A sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other
object, excluding falls resulting from violent blows or other purposeful actions (source: National Center
for Patient Safety)
Selection Basis:
“Falls per 100,000 patient days” has been endorsed as a serious reportable event by the NQF. While ASCs
have a relatively low incidence of adverse events in general, information regarding the incidence of patient
falls is not currently available. However, stakeholders have expressed a general interest in the public
reporting of such adverse events. Due to the use of anxiolytics, sedatives, and anesthetic agents as adjuncts to
procedures, patients undergoing outpatient surgery are at increased risk for falls.
Clinical Recommendation Statements:
According to the Agency for Healthcare Research and Quality’s Prevention of Falls in Acute Care guideline,
patient falls may be reduced by following a four-step approach: 1) evaluating and identifying risk factors for
falls in the older patient; 2) developing an appropriate plan of care for prevention; 3) performing a
comprehensive evaluation of falls that occur; and 4) performing a post-fall revision of plan of care as
appropriate.

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Additional information and resources, such as sample data collection forms and frequently asked questions
(FAQs) about the measures, can be found on the ASC Quality Collaboration website at www.ascquality.org.
Selected References:
 Institute for Clinical Systems Improvement (ICSI). Prevention of falls (acute care). Health care protocol.
Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2010 Apr. p 34.
 Boushon B, Nielsen G, Quigley P, Rutherford P, Taylor J, Shannon D. Transforming Care at the Bedside
How-to-Guide: Reducing Patient Injuries from Falls. Cambridge, MA: Institute for Healthcare
Improvement; 2008.
 ECRI Institute. Fall Injury Prevention Interventions. August 1, 2015.
 Joint Commission. 2011-2012 National Patient Safety Goals:
http://www.jointcommission.org/standards_information/npsgs.aspx.
 National Center for Patient Safety: United States Department of Veterans Affairs.
http://www.patientsafety.va.gov/professionals/onthejob/falls.asp.
 National Quality Forum. Serious Reportable Events in Healthcare – 2006 Update: A Consensus Report.
March 2007.
 Gray-Micelli D. Preventing falls in acute care. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s).
Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing
Company. 2008. p. 161-98.
 American Geriatrics Society, British Geriatrics Society, American Academy of Orthopedic Surgeons
(AGS/BGS/AAOS) Guidelines for the Prevention of Falls in Older Persons (2001). Journal of the
American Geriatrics Society, 49, 664-672.
 American Medical Directors Association (AMDA). Falls and fall risk. Columbia, MD: American
Medical Directors Association.
 ECRI Institute: Falls Prevention Strategies in Healthcare Settings (2006). Plymouth Meeting, PA.
 Institute for Clinical Systems Improvement. Prevention of Falls (Acute Care). Second Edition. April
2010.
 Resnick, B. (2003). Preventing falls in acute care. In: M. Mezey, T. Fulmer, I. Abraham (Eds.) & D.
Zwicker (Managing Ed.), Geriatric nursing protocols for best practice (2nd ed., pp. 141-164). New York:
Springer Publishing Company, Inc.
 University of Iowa Gerontological Nursing Interventions Research Center (UIGN). (2004). Falls
prevention for older adults. Iowa City, IA. University of Iowa Gerontological Nursing Interventions
Research Center, Research Dissemination Core.

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Material inside brackets ([and]) is new to this Specifications Manual version.

Measure Information Form
Measure Title: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant
Measure ID #: ASC-3
Quality Reporting Option: Claims-based outcome measure
Description: The number of admissions (patients) who experience a wrong site, side, patient, procedure, or
implant
Denominator: All ASC admissions
Inclusions: All ASC admissions
Exclusions: None
Numerator: All ASC admissions experiencing a wrong site, wrong side, wrong patient, wrong procedure, or
wrong implant
Inclusions: All ASC admissions experiencing a wrong site, wrong side, wrong patient, wrong procedure, or
wrong implant
Exclusions: None
Numerator Quality-Data Coding Options for Reporting:
 G8912: Patient documented to have experienced a wrong site, wrong side, wrong patient, wrong
procedure, or wrong implant event
 G8913: Patient documented not to have experienced a wrong site, wrong side, wrong patient, wrong
procedure, or wrong implant event
 G8907: Patient documented not to have experienced any of the following events: a burn prior to
discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong procedure, or wrong
implant event; or a hospital transfer or hospital admission upon discharge from the facility
Note: If using code G8912 or G8913, do not use code G8907.
Definitions:
 Admission – Completion of registration upon entry into the facility
 Wrong – Not in accordance with intended site, side, patient, procedure, or implant
Selection Basis:
“Surgery performed on the wrong body part,” “surgery performed on the wrong patient,” and “wrong
surgical procedure performed on a patient” have all been endorsed as serious reportable surgical events by
NQF. This outcome measure serves as an indirect measure of providers’ adherence to The Joint
Commission’s “Universal Protocol” guideline. The Joint Commission, an accreditation body, has developed
a “Universal Protocol” guideline for eliminating wrong site, wrong procedure, wrong person surgery. The
Universal Protocol is based on the consensus of experts and is endorsed by more than 40 professional
medical associations and organizations. To encompass the outcomes of all key identification verifications,
the ASC Quality Collaboration’s measure incorporates not only wrong site, wrong side, wrong patient, and
wrong procedure, but also wrong implant in its specifications.

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Clinical Recommendation Statements:
The Joint Commission’s “Universal Protocol” is based on the consensus of experts from the relevant clinical
specialties and professional disciplines and is endorsed by more than 40 professional medical associations
and organizations.
Additional information and resources, such as sample data collection forms and frequently asked questions
(FAQs) about the measures, can be found on the ASC Quality Collaboration website at www.ascquality.org.
Selected References:
 Joint Commission. Universal Protocol For Preventing Wrong Site, Wrong Procedure, Wrong Person
Surgery. Available at http://jointcommission.org/standards_information/up.aspx. Last accessed
December 14, 2010.
 American Academy of Ophthalmology. Recommendations of American Academy of Ophthalmology
Wrong Site Task Force. http://www.aao.org/Assets/c85186a8-5f17-422b-861efd4e4b061dff/635518426969930000/revised-wswiol-document-may-12-2014-august-finalrev-pdf.
 American Academy of Orthopaedic Surgeons. Consistency for Safety in Orthopedic Surgery.
Information Statement 1042. http://www.aaos.org/about/papers/advistmt/1042.asp.
 American College of Obstetricians and Gynecologists. ACOG committee opinion #464: patient safety in
the surgical environment. Obstet Gynecol. 2010; 116(3):786-790.
 American College of Surgeons. [ST-41] Statement on ensuring correct patient, correct site, and correct
procedure surgery Correct Site Surgery - American College of Surgeons.
 AORN. AORN Position Statement on Preventing Wrong-Patient, Wrong-Site, Wrong-Procedure Events.
AORN Position Statement Preventing Wrong-Patient, Wrong-Site, Wrong-Procedure Events.
 Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National
Academy Press, 2000.
 Joint Commission. 2011 National Patient Safety Goals.
http://www.jointcommission.org/standards_information/npsgs.aspx.
 National Quality Forum. Serious Reportable Events in Healthcare – 2006 Update: A Consensus Report.
March 2007.
 World Health Organization. WHO Guidelines for Safe Surgery 2009.
http://whqlibdoc.who.int/publications/2009/9789241598552_eng.pdf.

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.
Measure Information Form

Measure Title: All-Cause Hospital Transfer/Admission
Measure ID #: ASC-4
Quality Reporting Option: Claims-based outcome measure
Description: The percentage of ASC admissions (patients) who are transferred or admitted to a hospital
upon discharge from the ASC
Denominator: All ASC admissions
Inclusions: All ASC admissions
Exclusions: None
Numerator: ASC admissions requiring a hospital transfer or hospital admission upon discharge from the
ASC
Inclusions: ASC admissions requiring a hospital transfer or hospital admission upon discharge from the ASC
Exclusions: None
Numerator Quality-Data Coding Options for Reporting:
 G8914: Patient documented to have experienced a hospital transfer or hospital admission upon discharge
from ASC
 G8915: Patient documented not to have experienced a hospital transfer or hospital admission upon
discharge from ASC
 G8907: Patient documented not to have experienced any of the following events: a burn prior to
discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong procedure, or wrong
implant event; or a hospital transfer or hospital admission upon discharge from the facility
Note: If using code G8914 or G8915, do not use code G8907.
Definitions:
 Admission – Completion of registration upon entry into the facility
 Hospital Transfer/Admission – Any transfer/admission from an ASC directly to an acute care hospital
including hospital emergency room
 Discharge – Occurs when the patient leaves the confines of the ASC
Selection Basis:
The need for transfer/admission is an unanticipated, but sometimes necessary outcome. Hospital
transfers/admissions can result in unplanned cost and time burdens that must be borne by patients and payers.
Selected states have expressed an interest in the public reporting of such events. While hospital transfers and
admissions undoubtedly represent good patient care when necessary, high rates may be an indicator that
practice patterns or patient selection guidelines are in need of review.
Clinical Recommendation Statements:
No clinical practice guidelines specifically addressing transfers or admissions from ASCs to acute care
hospitals are available at this time.
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Additional information and resources, such as sample data collection forms and frequently asked questions
(FAQs) about the measures, can be found on the ASC Quality Collaboration website at www.ascquality.org.
Selected References:
 Coley K et al. Retrospective evaluation of unanticipated admissions and readmissions after same day
surgery and associated costs. J. Clin Anesth. 2002; 14:349-353.
 Lin D, Dalgorf D, Witterick IJ. Predictors of unexpected hospital admissions after outpatient endoscopic
sinus surgery: retrospective review. J Otolaryngol Head Neck Surg. 2008 Jun: 37(3):309-11.
 Hofer RE, Kai T, Decker PA, Warner DO. Obesity as a risk factor for unanticipated admissions after
ambulatory surgery. Mayo Clin Proc. 2008 Aug; 83(8):908-16.
 Tewfik MA, Frenkiel S, Gasparrini R, Zeitouni A, Daniel SJ, Dolev Y, Kost K, Samaha M, Sweet R,
Tewfik TL. Factors affecting unanticipated hospital admission following otolaryngologic day surgery. J
Otolaryngol. 2006 Aug; 35(4):235-41.
 Shirakami G, Teratani Y, Namba T, Hirakata H, Tazuke-Nishimura M, Fukuda K. Delayed discharge and
acceptability of ambulatory surgery in adult outpatients receiving general anesthesia. J Anesth.
2005:19(2):93-101.
 Lau H, Brooks DC. Predictive factors for unanticipated admissions after ambulatory laparoscopic
cholecystectomy. Arch Surg. 2001 Oct; 136(10):1150-3.
 Junger A, Klasen J, Benson M, Sciuk G, Hartmann B, Sticher J, Hempelmann G. Factors determining
length of stay of surgical day-case patients. Eur J Anaesthesiol. 2001 May; 18(5):314-21.
 Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery—a prospective study. Can J
Anaesth. 1998 Jul; 45(7):612-9.
 Margovsky A. Unplanned admissions in day-case surgery as a clinical indicator for quality assurance.
Aust N Z J Surg. 2000 Mar; 70(3):216-20.
 Lledó JB, Planells M, Espí A, Serralta A, García R, Sanahuja A. Predictive model of failure of outpatient
laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech. 2008 Jun; 18(3):248-53.
 Shaikh S, Chung F, Imarengiaye C, Yung D, Bernstein M. Pain, nausea, vomiting and ocular
complications delay discharge following ambulatory microdiscectomy. Can J Anaesth. 2003 May;
50(5):514-8.

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Measure Information Form
Measure Title: Prophylactic Intravenous (IV) Antibiotic Timing
Measure ID #: ASC-5
Quality Reporting Option: Claims-based process measure
Description: Intravenous (IV) antibiotics given for prevention of surgical site infection were administered
on time
Denominator: All ASC admissions with a preoperative order for a prophylactic IV antibiotic for prevention
of surgical site infection
Inclusions: All ASC admissions with a preoperative order for a prophylactic IV antibiotic for prevention of
surgical site infection
Exclusions: ASC admissions with a preoperative order for a prophylactic IV antibiotic for prevention of
infections other than surgical site infections (e.g., bacterial endocarditis); ASC admissions with a
preoperative order for a prophylactic antibiotic not administered by the intravenous route
Numerator: Number of ASC admissions with an order for a prophylactic IV antibiotic for prevention of
surgical site infection who received the prophylactic antibiotic on time
Inclusions: All ASC admissions with a preoperative order for a prophylactic IV antibiotic for prevention of
surgical site infection
Exclusions: None
Numerator Quality-Data Coding Options for Reporting:
 G8916: Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis,
antibiotic initiated on time
 G8917: Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis,
antibiotic not initiated on time
 G8918*: Patient without preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis
*Note: G8918 is to be reported for patients with no indication for, or no order for IV antibiotic prophylaxis
for surgical site infection. This does not place a case with this code in the denominator, but is necessary for
calculating the completeness of reporting.
Definitions:
 Admission – completion of registration after physical entry into the facility
 Antibiotic administered on time – antibiotic infusion is initiated within one hour prior to the time of the
initial surgical incision or the beginning of the procedure (e.g., introduction of endoscope, insertion of
needle, inflation of tourniquet) or two hours prior if Vancomycin or fluoroquinolones are administered
 Intravenous – administration of a drug within a vein, including bolus, infusion, or IV piggyback
 Order – a written order, verbal order, standing order, or standing protocol
 Prophylactic antibiotic – an antibiotic prescribed with the intent of reducing the probability of an
infection related to an invasive procedure. For purposes of this measure, the following antibiotics are
considered prophylaxis for surgical site infections: Ampicillin/sulbactam, Aztreonam, Cefazolin,
Cefmetazole, Cefotetan, Cefoxitin, Cefuroxime, Ciprofloxacin, Clindamycin, Ertapenem, Erythromycin,
Gatifloxacin, Gentamicin, Levofloxacin, Metronidazole, Moxifloxacin, Neomycin, and Vancomycin.
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Selection Basis:
The CMS Surgical Infection Prevention performance measure states, “Surgical site infections occur in 2–5
percent of clean extra-abdominal surgeries and up to 20 percent of intra-abdominal surgeries. Each infection
is estimated to increase a hospital stay by an average of 7 days and add over $3,000 in charges (1992 data).
Patients who develop surgical site infections are 60 percent more likely to spend time in an ICU (intensive
care unit), five times more likely to be readmitted to the hospital, and have twice the incidence of mortality.
Despite advances in infection control practices, surgical site infections remain a substantial cause of
morbidity and mortality among hospitalized patients. Studies indicate that appropriate preoperative
administration of antibiotics is effective in preventing infection. Systemic and process changes that promote
compliance with established guidelines and standards can decrease infectious morbidity.”
There is no literature available on variation in adherence to recommended prophylactic IV antibiotic timing
among ASC providers. However, variability in the accuracy of timing of administration has been
demonstrated in other clinical settings.
Clinical Recommendation Statements:
This performance measure is aligned with current surgical infection prevention guidelines recommending
that prophylactic antibiotics be administered within one hour prior to surgical incision, or within two hours
prior to incision when vancomycin or fluoroquinolones are used.
Selected References:
 Horan T, Culver D, Gaynes R, Jarvis W, Edwards J, and Reid C. Nosocomial infections in surgical
patients in the United States, January 1986-June 1992. National Nosocomial Infections Surveillance
(NNIS) System. Infect Control Hosp Epidemiol. 1993; 14(2):73-80.
 Marton W, Jarvis W, Culver D, and Haley R. Incidence and nature of endemic and epidemic nosocomial
infections. In: Bennett J, Brachman P, editor(s). Hospital infections. 3rd ed. Boston, MA: Little, Brown
and Co.; 1992. 577-596.
 Kirkland K, Briggs J, Trivette S, Wilkinson W, and Sexton D. The impact of surgical-site infections in
the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp
Epidemiol. 1999; 20(11):725-30.
 Burke J. Maximizing appropriate antibiotic prophylaxis for surgical patients: an update from LDS
Hospital, Salt Lake City. Clin Infect Dis. 2001; 33(Suppl 2):S78-83.
 Classen D et al. The timing of prophylactic administration of antibiotics and the risk of surgical wound
infection. NEJM. 1992; 326(5):281-286.
 Silver A et al. Timeliness and use of antibiotic prophylaxis in selected inpatient surgical procedures. The
Antibiotic Prophylaxis Study Group. Am J Surg. 1996; 171(6):548-552.
 Papaioannou N, Kalivas L, Kalavritinos J, and Tsourvakas S. Tissue concentrations of third-generation
cephalosporins (ceftazidime and ceftriaxone) in lower extremity tissues using a tourniquet. Arch Orthop
Trauma Surg. 1994; 113(3):167-9.
 Dounis E, Tsourvakas S, Kalivas L, and Giamacellou H. Effect of time interval on tissue concentrations
of cephalosporins after tourniquet inflation. Highest levels achieved by administration 20 minutes before
inflation. Acta Orthop Scand. 1995; 66(2):158-60.
 Friedrich L, White R, Brundage D, Kays M, Friedman R. The effect of tourniquet inflation on cefazolin
tissue penetration during total knee arthroplasty. Pharmacotherapy. 1990; 10(6):373-7.
 Steinberg JP, Barun BI, Hellinger WC, Kusek L, Bozikis MR, Bush AJ, Dellinger EP, Burke JP,
Simmons B, Kritchevsky SB, Trial to reduce antimicrobial prophylaxis errors (TRAPE) study group.
Timing of antimicrobial prophylaxis and the risk of surgical site infections: results from the trial to
reduce antimicrobial prophylaxis errors. Ann Surg 2009; 250(1):10-6.

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
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

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






Forbes SS, Stephen WJ, Harper WL, Loeb M, Smith R, Christoffersen EP, McLean RF. Implementation
of evidence-based practices for surgical site infection prophylaxis: results of a pre- and post-intervention
study. J Am Coll Surg. 2008 Sep; 207(3):336-41.
Koopman E, Nix DE, Erstad BL, Demeure MJ, Hayes MM, Ruth JT, Mattias KR. End-of-procedure
cefazolin concentrations after administration for prevention of surgical-site infection. Am J Health Syst
Pharm. 2007 Sep; 64(18):1927-34.
Manniën J, van Kasteren ME, Nagelkerke NJ, Gyssens IC, Kullberg BJ, Wille JC, de Boer AS. Effect of
optimized antibiotic prophylaxis on the incidence of surgical site infection. Infect Control Hosp
Epidemiol. 2006; 27(12):1340-6.
Cruse P. Wound infection surveillance. Rev Infect dis 1981; 3:734-737.
Cruse P, Foord R. The epidemiology of wound infection: a 10-year prospective study of 62,939 wounds.
Surg Clin North Am 1980; 60:27-40.
Coello R, Glenister H, Fereres J, et al. The cost of infection in surgical patients: a case-control study. J
Hosp Infect 1993; 25:239-250.
Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The impact of surgical-site
infections following orthopedic surgery at a community hospital and a university hospital: adverse
quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol 2002; 23:183-189.
Apisamthanarak A, Jones M, Waterman BM, Carroll CM, Bernardi R, Fraser VJ. Risk factors for spinal
surgical-site infections in a community hospital: a case-control study. Infect Control Hosp Epidemiol
2003; 24:31-36.
Encinosa WE, Hellinger FJ. The impact of medical errors on ninety-day costs and outcomes: An
examination of surgical patients. Health Serv Res. 2008 Dec: 43(6):2067-85.
Koch CG, Li L, Hixson E, Tang A, Gordon S, Longworth D, Phillips S, Blackstone E, Henderson JM. Is
it time to refine? An exploration and simulation of optimal antibiotic timing in general surgery. J Am
Coll Surg. 2013 Oct: 217(4):628-35.
Ho VP, Barie PS, Stein SL, Trencheva K, Milsom JW, Lee SW, Sonoda T. Antibiotic regimen and the
timing of prophylaxis are important for reducing surgical site infection after elective abdominal
colorectal surgery. Surg Infect (Larchmt). 2011 Aug: 12(4):255-60.
Hawn MT, Richman JS, Vick CC, Deierhoi RJ, Graham LA, Henderson WG, Itani KM. Timing of
surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA Surg. 2013 Jul: 148(7):64957.

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Measure Information Form
Measure Title: Safe Surgery Checklist Use
Measure ID #: ASC-6
Quality Reporting Option: Measure submitted via a web-based tool
[

]

Description: The use of a Safe Surgery Checklist for surgical procedures that includes safe surgery practices
during each of the three critical perioperative periods: the period prior to the administration of anesthesia, the
period prior to skin incision, and the period of closure of incision and prior to the patient leaving the
operating room
Measure ascertains response to the following question:
 Does/did your facility use a safe surgery checklist based on accepted standards of practice during the
designated period? Yes/No
Annual data submission period: See the timeline posted to QualityNet.org for this measure; select ASCs
and then Data Submission in the drop-down menu. Data entry will be achieved through the secure side of
QualityNet.org via an online tool available to authorized users.
Examples for Safe Surgery Practices*
First critical point (period
prior to administering
anesthesia)





Verbal confirmation of
patient identity
Mark surgical site
Check anesthesia
machine/medication
Assessment of allergies,
airway, and aspiration risk

Third critical point (period of
closure of incision and prior to
patient leaving the operating
room)

Second critical point (period
prior to skin incision)






Confirm surgical team
members and roles
Confirm patient identity,
procedure, and surgical
incision site
Administration of antibiotic
prophylaxis within 60 minutes
before incision
Communication among
surgical team members of
anticipated critical events
Display of essential imaging as
appropriate





Confirm the procedure
Complete count of surgical
instruments and accessories
Identify key patient concerns
for recovery and management
of the patient

*Safe surgery checklist items are not limited to the examples listed in this table.

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Measure Information Form
Measure Title: ASC Facility Volume Data on Selected ASC Surgical Procedures
Measure ID #: ASC-7
Quality Reporting Option: Measure submitted via a web-based tool
[

]

Description: The aggregate count of selected surgical procedures – Most ASC procedures fall into one of
eight categories: Eye, Gastrointestinal, Genitourinary, Musculoskeletal, Nervous System, Respiratory, Skin,
and Multi-system. The eight categories and corresponding HCPCS are listed in the table below.* The
procedures and codes in Table 2 were selected based on recent ASC data.
Measure ascertains response to the following question(s):
 What was the aggregate count of selected surgical procedures per category?
Annual data submission period: See the timeline posted to QualityNet.org for this measure; select ASCs
and then Data Submission in the drop-down menu. Data entry will be achieved through the secure side of
QualityNet.org via an online tool available to authorized users.
*Please note the categories and HCPCS for ASC-7: ASC Facility Volume Data on Selected ASC Surgical
Procedures will be populated here in November 2017 for encounters from 01-01-17 through 12-31-17.
[

]

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Measure Information Form
Measure Title: Influenza Vaccination Coverage among Healthcare Personnel
Measure ID #: ASC-8
Quality Reporting Option: CMS required ASCs participating in the CMS Ambulatory Surgical Center
Quality Reporting Program to report data collected by the Centers for Disease Control and Prevention (CDC)
via the National Healthcare Safety Network (NHSN).
Description: For more information about the NHSN measure, see the resources located at
http://www.cdc.gov/nhsn.
Definition for Healthcare Personnel (HCP) – Facilities must report vaccination data for three categories of
HCP: employees on payroll; licensed independent practitioners (who are physicians, advanced practice
nurses, and physician assistants affiliated with the hospital but not on payroll); and students, trainees, and
volunteers aged 18 or older. Reporting data on the optional, other contract personnel category is not required
at this time. All HCP physically working in the facility for at least one day or more between October 1 and
March 31 should be counted. Data on vaccinations received at the facility, vaccinations received outside of
the facility, medical contraindications, and declinations are reported for the three categories of HCP.
[

]

Direct questions regarding NHSN training, enrollment, and submission to: NHSN@cdc.gov.

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Measure Information Form
Measure Title: Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in
Average Risk Patients
Measure ID #: ASC-9
Quality Reporting Option: Measures submitted via a web-based tool
[

]

Description: Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without
biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat
colonoscopy documented in their colonoscopy report
Numerator Statement: Patients who had a recommended follow-up interval of at least 10 years for repeat
colonoscopy documented in their colonoscopy report
Denominator Statement: All patients aged 50 to 75 years of age receiving screening colonoscopy without
biopsy or polypectomy
Denominator Criteria (Eligible Cases):
Patients aged ≥ 50 and ≤ 75 on date of encounter
and
ICD-10-CM Diagnosis code: Z12.11
and
CPT or HCPCS: 44388, 45378, G0121
without
CPT Category I Modifiers: 52, 53, 73, 74
without
ICD-10-CM Diagnosis codes: Z83.71, Z86.010, Z80.0, Z85.038
Denominator Exclusions:
 Documentation of medical reason(s) for not recommending at least a 10 year follow-up interval (e.g.,
above average risk, inadequate prep). Medical reason(s) are at the discretion of the physician.
Documentation indicating no follow-up colonoscopy is needed or recommended is only acceptable if the
patient’s age is documented as the reason. Documentation of a medical condition or finding can be used
as a medical reason(s) for denominator exclusion purposes only if the documented recommended followup interval is less than 10 years.
Examples:
 Diverticulitis documented in the medical record and a follow-up interval of 5 years in the
colonoscopy report.
 Family history of colon cancer and a follow-up interval of 3 years documented in the
colonoscopy report.
 Less than adequate prep documented in the medical record with a repeat colonoscopy in 3
years in the colonoscopy report.
Annual Data Submission Period: See the timeline posted to QualityNet.org for this measure; select ASCs
and then Data Submission in the drop-down menu. Data entry will be achieved through the secure side of
QualityNet.org via an online tool available to authorized users.

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Additional Instructions: Patients will be counted in the numerator if there is reference in the final
colonoscopy report that the appropriate follow-up interval for the repeat colonoscopy is at least 10 years
from the date of the current colonoscopy (i.e., the colonoscopy performed during the measurement period). A
range that includes “10 years” (e.g., 7 to 10 years) is not acceptable.

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Measure Information Form
Measure Title: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of
Adenomatous Polyps – Avoidance of Inappropriate Use
Measure ID #: ASC-10
Quality Reporting Option: Measures submitted via a web-based tool
[

]

Description: Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a
history of a prior colonic polyp(s) in previous colonoscopy findings, who had a follow-up interval of 3 or
more years since their last colonoscopy
Numerator Statement: Patients who had an interval of 3 or more years since their last colonoscopy
Denominator Statement: All patients aged 18 years and older receiving a surveillance colonoscopy with a
history of a prior colonic polyp(s) in previous colonoscopy findings
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
and
Diagnosis for history of colonic polyp(s) (ICD-10-CM): Z86.010
and
CPT or HCPCS: 44388, 44389, 44392, 44394, 45378, 45380, 45381, 45384, 45385, G0105
without
CPT Category I Modifiers: 52, 53, 73, or 74
Denominator Exclusions:
 Documentation of medical reason(s) for an interval of less than 3 years since the last colonoscopy (e.g.,
patients with high risk for colon cancer, last colonoscopy incomplete, last colonoscopy had inadequate prep,
piecemeal removal of adenomas/polyps, or last colonoscopy found greater than 10 adenomas/polyps).
Medical reason(s) are at the discretion of the physician. “History of colonic polyps” is not an acceptable
reason to exclude cases from the denominator. A patient must have a history of colonic polyps to be eligible
for the measure. Documentation of a medical condition or finding can be used as a medical reason(s) for
denominator exclusion purposes only if the previous colonoscopy was less than 3 years prior.
 Documentation of system reason(s) clearly documented in the current medical record for an interval of less
than 3 years since the last colonoscopy (e.g., unable to locate previous colonoscopy report). For a system
reason all of the following must be present in the medical record.
 The interval since the last colonoscopy is less than 3 years; and
 A medical reason for an interval of less than 3 years is not documented; and
 A “system reason” is documented (e.g., previous colonoscopy report not available, unable to locate
last colonoscopy report).
Annual Data Submission Period: See the timeline posted to QualityNet.org for this measure; select ASCs
and then Data Submission in the drop-down menu. Data entry will be achieved through the secure side of
QualityNet.org via an online tool available to authorized users.
Additional Instructions: For the purpose of this measure, a surveillance colonoscopy is defined as the
colonoscopy performed after a colonic polyp(s) has been detected and removed. The denominator of this
measure is the total number of patients ≥ 18 years of age receiving a surveillance colonoscopy. The
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numerator is the number of patients receiving a surveillance colonoscopy 3 years or greater after the
colonoscopy showing the colonic polyp. Information regarding the performance interval can be obtained
from medical record documentation.

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Measure Information Form
Measure Title: Cataracts – Improvement in Patient’s Visual Function within 90 Days Following Cataract
Surgery
Measure ID #: ASC-11*
Quality Reporting Option: Measure submitted via a web-based tool
[

]

Description: Percentage of patients aged 18 years and older who had cataract surgery and had improvement
in visual function achieved within 90 days following the cataract surgery
Numerator Statement: Patients who had improvement in visual function achieved within 90 days following
cataract surgery, based on completing both a pre-operative and post-operative visual function instrument
Denominator Statement: All patients aged 18 years and older who had cataract surgery and completed both
a pre-operative and post-operative visual function instrument
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years
and
CPT (with or without modifiers): 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984
Excluded Population: Patients who did not complete both a pre-operative and post-operative survey
Annual Data Submission Period: See the timeline posted to QualityNet.org for this measure; select ASCs
and then Data Submission in the drop-down menu. Data entry will be achieved through the secure side of
QualityNet.org via an online tool available to authorized users.
Data Collection Approach: Include procedures performed from the beginning of the reporting year through
90 days prior to the end of the reporting period. This will allow the postoperative period to occur.
Additional Instructions: Definition for Survey: An appropriate data collection instrument is an assessment
tool that has been validated for the population for which it is being used; this measure utilizes a visual
function survey. While it is recommended that the facility obtain the survey results from the appropriate
physician or optometrist, the surveys can be administered by the facility via phone, mail, email, or during
clinician follow-up. For this measure, the same data collection instrument (i.e., survey) must be used preoperatively and post-operatively.
Examples of tools for visual function assessment include, but are not limited to: National Eye InstituteVisual Function Questionnaire (VFQ- http://www.rand.org/health/surveys_tools/vfq.html), the Visual
Function (VF)-14, the modified VF-8, the Activities of Daily Vision Scale (ADVS), the Catquest, and the
modified Catquest-9. For each of the VF tools (VF-14 or VF-8R), all questions have equal weight; only nonmissing questions are included, and the total weight is 100.
*Finalized in the CY 2015 OPPS/ASC final rule, ASCs have the option to voluntarily collect and submit data
for ASC-11 for the CY 2017 payment determination and subsequent years. All data submitted voluntarily
will be publically reported as discussed in the CY 2014 OPPS/ASC proposed rule (Vol. 78, No. 139
Proposed Rule, pp.43664, 43669).

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Centers for Medicare & Medicaid Services (CMS)
Facility 7-Day Risk Standardized Hospital Visit Rate after Outpatient Colonoscopy Measure
Introduction
This section of the manual includes the Measure Information Form (MIF) for the CMS Facility 7-Day RiskStandardized Hospital Visit Rate after Outpatient Colonoscopy measure. This is an administrative claimsbased measure, so there is no data abstraction responsibility on the part of the facility. The measure includes
outpatient colonoscopies performed among Medicare Fee-for-Service (FFS) beneficiaries aged ≥ 65 years.
CMS has finalized adoption of the measure into the ASCQR Program for payment determination beginning
in calendar year 2018.
This measure was developed by a team of clinical and statistical experts from the Yale New Haven Health
Services Corporation/Center for Outcomes Research and Evaluation (YNHHSC/CORE), under contract to
CMS. The measure is currently endorsed by the National Quality Forum (NQF #2539).
The information in the following MIF is being provided in the interest of transparency and to promote
understanding of methodology on the part of the facility and vendor communities. Additional background
information about the measure methodology can be found in the measure technical report
(https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/Measure-Methodology.html), the 2015 Measure Specifications Report
(https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&ci
d=1228775197506), and the 2016 Measure Updates and Specifications Report
https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid
=1228775214597. Questions and comments about the measure should be directed to
CMSColonoscopyMeasure@yale.edu.
CMS calculates a facility-level risk-standardized unplanned hospital visit rate for all eligible facilities.
Facilities and their ORYX® Vendors do not have sufficient data to produce facilities’ risk-standardized
results. CMS inpatient and outpatient claims data are used to determine whether a beneficiary has had an
unplanned hospital visit to any acute care hospital within 7 days of the outpatient colonoscopy. In addition,
CMS extracts and utilizes physician office, inpatient, and outpatient claims data from the year prior to the
colonoscopy as well as claims data from the colonoscopy to risk adjust the facility-level outcome rates.

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Measure Information Form
Measure Title: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy
Measure ID #: ASC-12
Quality Reporting Option: CMS Outcome Measure (Claims-Based)
Description: The measure estimates a facility-level rate of risk-standardized, all-cause, unplanned hospital
visits within 7 days of an outpatient colonoscopy among Medicare Fee-for-Service (FFS) patients aged 65
years and older.
Rationale: This measure will reduce adverse patient outcomes associated with preparation for colonoscopy,
the procedure itself, and follow-up care by capturing and making more visible to providers and patients all
unplanned hospital visits following the procedure. The measure score will assess quality and inform quality
improvement.
Type of Measure: Outcome
Improvement Noted As: A decrease in the facility-level risk-standardized unplanned hospital visit rate
Numerator Statement:
This outcome measure does not have a traditional numerator and denominator like a core process measure
(e.g., percentage of adult patients with diabetes aged 18-75 years receiving one or more hemoglobin A1c
tests per year); thus, we are using this field to define the outcome. The calculation of the rate is defined
below under Measure Calculation.
The outcome for this measure is all-cause, unplanned hospital visits within 7 days of an outpatient
colonoscopy. The measure defines a hospital visit as any emergency department (ED) visit, observation stay,
or unplanned inpatient admission.
Denominator Statement:
The target population for this measure includes low-risk colonoscopies performed in the outpatient setting
for Medicare FFS patients aged 65 years and older. For implementation in the ASCQR Program, the measure
will be calculated among ambulatory surgical centers (ASCs).
Included Populations:
Outpatient colonoscopies for Medicare FFS patients aged 65 years and older. CMS FFS beneficiaries with an
outpatient colonoscopy are included if the patient has been enrolled in Part A and Part B Medicare for the 12
months prior to the date of procedure to ensure a full year of administrative data for risk-adjustment.
The measure is focused on low-risk colonoscopies. The measure did not include colonoscopy CPT procedure
codes that reflected fundamentally higher-risk or different procedures. Qualifying colonoscopies billed with
a concurrent high-risk colonoscopy procedure code were not included in the measure; the 2016 Measure
Updates and Specifications Report at the link above contains the complete listing of all high-risk procedure
codes.

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CPT Codes that define the patient cohort:
G0121 Colonoscopy on individual not meeting criteria for high risk
G0105 Colonoscopy on individual at high risk of colorectal cancer
45378
Diagnostic colonoscopy
45380
Colonoscopy with biopsy
45385
Colonoscopy with ablation of lesion(s)/polypectomy by snare
45384
Colonoscopy with ablation of lesion(s)/polypectomy by hot biopsy forceps or bipolar cautery
45383
Colonoscopy with ablation of lesion(s)/polypectomy by other techniques (i.e., techniques other
than 45384/45385)
45381
Colonoscopy, with directed submucosal injection, any substance
45388
Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and
post-dilation and guide wire passage, when performed)
G6024 Colonoscopy, flexible; proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other
lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare
Cohort Exclusions (excluded colonoscopies):
 Colonoscopies for patients who lack continuous enrollment in Medicare FFS Parts A and B in the 7 days
after the procedure.
 Colonoscopies that occur concurrently with high-risk upper gastrointestinal (GI) endoscopy procedures.
 Colonoscopies for patients with a history of inflammatory bowel disease (IBD) or diagnosis of IBD at
time of index colonoscopy or on a subsequent hospital visit outcome claim.
 Colonoscopies for patients with a history of diverticulitis or diagnosis of diverticulitis at time of index
colonoscopy or on a subsequent hospital visit outcome claim.
 Colonoscopies followed by a subsequent outpatient colonoscopy procedure within 7 days.
The 2016 Measure Updates and Specifications Report contains complete coding for all exclusions.
[Note: The codes in Table 1 have been modified to replace the las t letter X with an as teris k*]

Table 1: Inflammatory Bowel Disease (IBD) ICD-10-CM Diagnosis Codes
ICD-10ICD-10-CM Code Description
CM Code
K50.0*
Crohn’s disease of small intestine
K50.1*

Crohn’s disease of large intestine

K50.8*

Crohn’s disease of both small and large intestine

K50.9*

Crohn’s disease, unspecified

K51.2*

Ulcerative (chronic) proctitis

K51.3*

Ulcerative (chronic) rectosigmoiditis

K51.4*

Inflammatory polyps of colon

K51.5*

Left sided colitis

K51.0*

Ulcerative (chronic) pancolitis

K51.8*

Other ulcerative colitis

K51.9*

Ulcerative colitis, unspecified

Note: for the ICD-9 codes relevant to the calculation of the measure for the CY2016 period, refer to v5.1 of
the manual.
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Table 2: Diverticulitis ICD-10-CM Diagnosis Codes
ICD-10ICD-10-CM Code Description
CM Code
K57.20
Diverticulitis of large intestine with perforation and abscess without bleeding
K57.32

Diverticulitis of large intestine without perforation or abscess without bleeding

K57.40

Diverticulitis of both small and large intestine with perforation and abscess without bleeding

K57.52

Diverticulitis of both small and large intestine without perforation or abscess without bleeding

K57.80

Diverticulitis of intestine, part unspecified, with perforation and abscess without bleeding

K57.92

Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding

K57.21

Diverticulitis of large intestine with perforation and abscess with bleeding

K57.33

Diverticulitis of large intestine without perforation or abscess with bleeding

K57.41

Diverticulitis of both small and large intestine with perforation and abscess with bleeding

K57.53

Diverticulitis of both small and large intestine without perforation or abscess with bleeding

K57.81

Diverticulitis of intestine, part unspecified, with perforation and abscess with bleeding

K57.93

Diverticulitis of intestine, part unspecified, without perforation or abscess with bleeding

Note: For the ICD-9 codes relevant to the calculation of the measure for the CY2016 period, refer to v5.1 of
the manual.
Admissions not counted in the outcome (“Planned admissions”):
Admissions identified as planned by the planned admission algorithm are not counted in the outcome. The
“algorithm” is a set of criteria for classifying admissions as planned using Medicare claims. The algorithm
identifies admissions that are typically planned and may occur within 7 days of an outpatient colonoscopy.
CMS based the planned admission algorithm on three principles:
1. A few specific, limited types of care are always considered planned (transplant surgery, maintenance
chemotherapy, rehabilitation);
2. Otherwise, a planned admission is defined as a non-acute admission for a scheduled procedure; and
3. Admissions for acute illness or for complications of care are never planned.
The planned admission algorithm uses a flowchart and four tables of procedures and conditions to
operationalize these principles and to classify inpatient admissions as planned. ED visits and observation
stays are never considered planned. The flowchart and tables are available in the 2016 Measure Updates and
Specifications Report, located at
https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid
=1228775214597.
Risk Adjustment:
The measure’s approach to risk adjustment is tailored to, and appropriate for, a publicly reported outcome
measure as articulated in published scientific guidelines (Krumholz et al., 2006; Normand et al., 2007).
The measure uses a two-level hierarchical logistic regression model to estimate facility-level riskstandardized hospital visit rates. This approach accounts for the clustering of patients within facilities and
variation in sample size across facilities.
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The risk-standardization model has 15 patient-level variables (age, concomitant upper GI endoscopy,
polypectomy during the procedure, and 12 comorbidity variables). The measure defines comorbidity
variables using condition categories (CCs), which are clinically meaningful groupings of the many thousands
of ICD-10-CM diagnosis codes. Certain CCs are considered possible complications of care; therefore, the
measure does not risk-adjust for them if they occur only at the time of the procedure. This is because only
comorbidities that convey information about the patient at the time of the procedure or in the 12 months
prior, and not complications that arose during the colonoscopy procedure are included in the risk adjustment.
The 2016 Measure Updates and Specifications Report contains complete definitions of risk factors and CCs
that are considered possible complications of care and are not risk-adjusted for if they occur only at the time
of the procedure.
The patient-level risk adjustment variables are:
Patient-level variables

Ris k-adjus ted variables

Demographics

Age (categorized; 65-69; 70-74; 75-79; 80-84; 85+)

Procedural factors

Comorbidities

Concomitant Endoscopy
Polypectomy during Procedure
Chronic Heart Failure
Ischemic Heart Disease
Stroke/Transient Ischemic Attack (TIA)
Chronic Lung Disease
Metastatic Cancer
Liver Disease
Iron Deficiency Anemia
Disorders of Fluid, Electrolyte, Acid-Base
Pneumonia
Psychiatric Disorders
Drug and Alcohol Abuse/Dependence
Arrhythmia
Age Categorized x Arrhythmia Interaction

Note: The relationship between age and risk of a hospital visit within 7 days was modified by the presence or
absence of a cardiac arrhythmia (p-value for interaction <0.001). Therefore, we included an interaction term
(age categorized x arrhythmia) in the final model.
Full details of the development of the risk-standardization model for this measure are available at:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/Measure-Methodology.html.
Data Collection Approach: Medicare administrative claims and enrollment data
Data Accuracy: The administrative claims data used to calculate the measure are maintained by CMS’
Office of Information Services. The data undergo additional quality assurance checks during measure
development and maintenance.
Measure Analysis Suggestions: None
Sampling: No
Data Reported As: Facility-level 7-day risk-standardized unplanned hospital visit rate following outpatient
colonoscopy
ASCQR Specifications Manual
Encounter dates 01-01-17 (1Q17) through 12-31-17 (4Q17) v6.0a
CPT® only copyright 2016 American Medical Association. All rights reserved.

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Measure Calculation:
The measure estimates facility-level 7-day risk-standardized unplanned hospital visit rates using hierarchical
logistic regression modeling (a form of hierarchical generalized linear modeling [HGLM]). In brief, the
approach simultaneously models two levels (patient and facility) to account for the variance in patient
outcomes within and between facilities. At the patient level, the model adjusts the log-odds of a hospital visit
within 7 days of the procedure for age, procedural factors, and selected clinical covariates. At the facility
level, it estimates the facility-specific intercepts as arising from a normal distribution. The facility intercept
represents the underlying risk of a hospital visit within 7 days after a colonoscopy at that facility while
accounting for patient risk. The facility-specific intercepts also account for the clustering (non-independence)
of patients within the same facility. If there were no differences among facilities, then after adjusting for
patient risk the facility-specific intercepts would be identical across all facilities.
The statistical modeling approach is described fully in the original technical report:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/Measure-Methodology.html.
Selected References:
 Krumholz HM, Brindis RG, Brush JE, et al. Standards for Statistical Models Used for Public Reporting
of Health Outcomes: An American Heart Association Scientific Statement From the Quality of Care and
Outcomes Research Interdisciplinary Writing Group: Cosponsored by the Council on Epidemiology and
Prevention and the Stroke Council Endorsed by the American College of Cardiology Foundation.
Circulation. 2006; 113 (3): 456-462.
 Normand S-LT, Shahian DM. Statistical and Clinical Aspects of Hospital Outcomes Profiling. Stat Sci.
2007; 22-(2): 206-226.

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Material inside brackets ([and]) is new to this Specifications Manual version.

Quality-Data Coding & Sampling Specifications
ASC-1 through ASC-4  A Quality Data Code (QDC) has been established to report that the patient did not
experience the events for four of the five claims-based outcome measures. If this code is used, none of the
other QDCs should be used for these four measures.
G8907: Patient documented not to have experienced any of the following events: a burn prior to discharge; a
fall within the facility; wrong site, wrong side, wrong patient, wrong procedure, or wrong implant
event; or a hospital transfer or hospital admission upon discharge from the facility.
ASC-5 − Measure ASC-5 applies to all ASCs regardless of specialty or procedure performed. CMS requires
all facilities to report on the ASC-5 measure for all Medicare Fee-for-Service (FFS) patients, even if there is
no indication for or order for perioperative antibiotics (G8918). This requirement is necessary in order to
assess completeness of reporting.
Important: For surgical patients with an order for prophylactic antibiotics, information on the fifth measure,
Prophylactic IV Antibiotic Timing, will be reported separately. If the patient received the prophylactic
antibiotic on time and did not experience any of the events (a burn prior to discharge; a fall within the
facility, wrong site, wrong side, wrong patient, wrong procedure, or wrong implant event; or a hospital
transfer or hospital admission upon discharge from the facility), the code listed above (G8907) would be
used in addition to G8916. See each measure for the list of applicable codes.
For more information on measures ASC-1–ASC-5, see individual measure specifications in this manual.
ASC-9, ASC-10, and ASC-11*  The sampling size specifications for ASC-9, ASC-10, and ASC-11* have
been established and are specified in the table below.
Table 3: Sample size requirements per year per ASC for Endoscopy/Polyp Surveillance
(ASC-9 and ASC-10) or Cataracts (ASC-11*) measures.**
Population Per Year

0-900

Yearly Sample Size

Quarterly Sample Size

Monthly Sample Size

Population Per Year

≥ 901

Yearly Sample Size

Quarterly Sample Size

Monthly Sample Size

*Voluntary submission of data for ASC-11 began January 2015.
**For ASCs with fewer than 63 cases, the total population of cases is required.

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Appendix A: Glossary of Terms
Admission: Completion of registration upon entry into the facility.
Antibiotic administered on time: Antibiotic infusion is initiated within one hour prior to the time of the
initial surgical incision or the beginning of the procedure (e.g., introduction of endoscope, insertion of
needle, inflation of tourniquet) or two hours prior if vancomycin or fluoroquinolones are administered.
Burn: Unintended tissue injury caused by any of the six recognized mechanisms: scalds, contact, fire,
chemical, electrical, or radiation (e.g., warming devices, prep solutions, electrosurgical unit, or laser).
Discharge: Occurs when the patient leaves the confines of the ASC.
Fall: A sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other
object, excluding falls resulting from violent blows or other purposeful actions (National Center for Patient
Safety).
Healthcare personnel (HCP): Facilities must report vaccination data for three categories of HCP:
employees on payroll; licensed independent practitioners (who are physicians, advanced practice nurses, and
physician assistants affiliated with the hospital but not on payroll); and students, trainees, and volunteers
aged 18 or older. All HCP physically working in the facility for at least one day or more between October 1
and March 31 should be counted. Data on vaccinations received at the facility, vaccinations received outside
of the facility, medical contraindications, and declinations are reported for the three categories of HCP.
Hospital transfer/admission: Any transfer/admission from an ASC directly to an acute care hospital
including hospital emergency room.
Intravenous: Administration of a drug within a vein, including bolus, infusion, or IV piggyback.
Order: A written order, verbal order, standing order, or standing protocol.
Prophylactic antibiotic: An antibiotic prescribed with the intent of reducing the probability of an infection
related to an invasive procedure. For purposes of the Prophylactic IV Antibiotic Timing measure, the
following antibiotics are considered prophylaxis for surgical site infections: Ampicillin/sulbactam,
Aztreonam, Cefazolin, Cefmetazole, Cefotetan, Cefoxitin, Cefuroxime, Ciprofloxacin, Clindamycin,
Ertapenem, Erythromycin, Gatifloxacin, Gentamicin, Levofloxacin, Metronidazole, Moxifloxacin,
Neomycin, and Vancomycin.
Quality Data Code (QDC): Non-payable Healthcare Common Procedure Coding System (HCPCS) codes
comprised of specified CPT Category II codes and/or G-codes that describe the clinical action required by a
measure’s numerator.
Wrong: Not in accordance with intended site, side, patient, procedure, or implant.

Appendix A-30

All content on this page is new to this manual vers ion

Appendix B: Preview Section

The Preview Section provides information on new measures. The information provided in this section should
not be programmed or submitted. The measure(s) identified in this section are not currently collected.
No new measures have been introduced for the CY 2019 payment determination. The measures below were
finalized in the ASCQR Program for the CY 2020 payment determination and subsequent years per the Final
Rule: https://www.gpo.gov/fdsys/pkg/FR-2016-11-14/pdf/2016-26515.pdf (pp. 79797-79818).
ASC-13: Normothermia Outcome
Measure Background and Overview:
“Perioperative hypothermia is associated with numerous adverse outcomes, including: Cardiac
complications; surgical site infections; impaired coagulation; and colligation of drug effects; as well as postanesthetic shivering and thermal discomfort. When intraoperative normothermia is maintained, patients
experience fewer adverse outcomes and their overall care costs are lower….We expect the measure will
promote improvement in patient care over time, because measurement coupled with transparency in publicly
reporting of measure information would make patient outcomes following procedures performed under
general or neuraxial anesthesia more visible to ASCs and patients and incentivize ASCs to incorporate
quality improvement activities to reduce perioperative hypothermia and associated complications where
necessary.” (81FR79798)
Measure Calculation and Reporting:
“This measure is based on aggregate measure data collected via chart abstraction by the ASC and submitted
via a CMS online data submission tool (that is, QualityNet). We proposed that the data collection period for
the proposed ASC-13 measure would be the calendar year 2 years prior to the applicable payment
determination year. For example, for the CY 2020 payment determination, the data collection period would
be CY 2018. We also proposed that ASCs submit these data to CMS during the time period of January 1 to
May 15 in the year prior to the affected payment determination year. For example, for the CY 2020 payment
determination, the submission period would be January 1, 2019 to May 15, 2019.” (81FR79799)
“The outcome measured in the proposed ASC-13 measure is the percentage of patients having surgical
procedures under general or neuraxial anesthesia of 60 minutes or more in duration who are normothermic
within 15 minutes of arrival in the post-anesthesia care unit (PACU). The numerator is the number of surgery
patients with a body temperature equal to or greater than 96.8 degrees Fahrenheit/36 degrees Celsius
recorded within 15 minutes of arrival in the PACU. The denominator is all patients, regardless of age,
undergoing surgical procedures under general or neuraxial anesthesia of greater than or equal to 60
minutes in duration.” (81FR79799)
ASC-14: Unplanned Anterior Vitrectomy
Measure Background and Overview:
“An unplanned anterior vitrectomy is performed when vitreous inadvertently prolapses into the anterior
segment of the eye during cataract surgery….While unplanned anterior vitrectomy rates are relatively low,
complications from this procedure may result in poor visual outcomes and other complications, including
retinal detachment. Cataract surgery is the most common surgery performed in ASCs; therefore, this measure
is of interest to the ASC Program….We expect the measure would promote improvement in patient care over
time, because measurement coupled with transparency in publicly reporting measure information would
make the rate of this unplanned procedure at ASCs more visible to both ASCs and patients and would
incentivize ASCs to incorporate quality improvement activities to reduce the occurrence of unplanned
anterior vitrectomies.” (81FR79801)

Appendix B-31

Measure Calculation and Reporting:
“The outcome measured in the proposed ASC–14 measure is the percentage of cataract surgery patients who
have an unplanned anterior vitrectomy. The numerator for this measure is all cataract surgery patients who
had an unplanned anterior vitrectomy. The denominator is all cataract surgery patients.” (81FR79802)
“This measure is based on aggregate measure data collected via chart abstraction by the ASC and submitted
via a CMS online data submission tool (that is, QualityNet). We proposed that the data collection period for
the proposed ASC–14 measure would be the calendar year 2 years prior to the applicable payment
determination year. For example, for the CY 2020 payment determination, the data collection period would
be CY 2018. We also proposed that ASCs submit these data to CMS during the time period of January 1 to
May 15 in the year prior to the affected payment determination year. For example, for the CY 2020 payment
determination, the submission period would be January 1, 2019 to May 15, 2019.” (81FR79802)
ASC-15a–e: Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and
Systems (OAS CAHPS) Survey Measures
The three OAS CAHPS composite survey based measures are:
ASC-15a: OAS CAHPS—About Facilities and Staff;
ASC-15b: OAS CAHPS—Communication About Procedure; and
ASC-15c: OAS CAHPS—Preparation for Discharge and Recovery.
The two global survey based measures are:
ASC-15d: OAS CAHPS—Overall Rating of Facility; and
ASC-15e: OAS CAHPS—Recommendation of Facility.
Measure Background and Overview:
“Currently…there is not one standardized survey in use to assess patient experiences with care in ASCs that
would allow valid comparisons across ASCs. Patient-centered experience of care measures are a component
of the 2016 CMS Quality Strategy, which emphasizes patient-centered care by rating patient experience as a
means for empowering patients and improving the quality of their care. In addition, information on patient
experience with care at a provider/facility is an important quality indicator to help providers and facilities
improve services furnished to their patients and to assist patients in choosing a provider/facility at which to
seek care….The OAS CAHPS Survey was developed as part of U.S. Department of Health and Human
Services’ (HHS) Transparency Initiative to measure patient experiences with ASC care.” (81FR79803)
“The OAS CAHPS Survey contains 37 questions that cover topics such as access to care, communications,
experience at the facility, and interactions with facility staff. The survey also contains two global rating
questions and asks for self-reported health status and basic demographic information (race/ethnicity,
educational attainment level, languages spoken at home, among others).” (81FR79803)
Measure Calculation and Reporting:
“These measure calculations will be used for public reporting purposes only.” (81FR79805)
“We proposed that the data collection period for the OAS CAHPS Survey measures would be the calendar
year 2 years prior to the applicable payment determination year. For example, for the CY 2020 payment
determination, ASCs would be required to collect data on a monthly basis, and submit this collected data on
a quarterly basis, for January 1, 2018–December 31, 2018 (CY 2018).” (81FR79804)
“To meet the OAS CAHPS Survey requirements for the ASCQR Program, we proposed that ASCs contract
with a CMS approved vendor to collect survey data for eligible patients at the ASCs on a monthly basis and
report that data to CMS on the ASC’s behalf by the quarterly deadlines established for each data collection
period. (81FR79812)
“Information about the list of approved survey vendors and how to authorize a vendor to collect data on an
ASC’s behalf is available through the OAS CAHPS Survey Web site at: https://oascahps.org/.” (81FR79823)

Appendix B-32

“We are finalizing our proposal to adopt the ASC-15a–e: Outpatient and Ambulatory Surgery Consumer
Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey measures for the ASCQR Program
for the CY 2020 payment determination and subsequent years as proposed with a clarification that ASCs that
anticipate receiving more than 300 surveys are required to either: (1) randomly sample their eligible patient
population, or (2) survey their entire OAS CAHPS eligible patient population.” (81FR79817)
Reference:
Federal Register /Vol. 81, No. 219 /Monday, November 14, 2016 /Rules and Regulations. Retrieved from
https://www.gpo.gov/fdsys/pkg/FR-2016-11-14/pdf/2016-26515.pdf

Appendix B-33

File Type	application/pdf
File Title	Appendix B_ v6.0a
Subject	ASC, Specifications Manual, v6.0a, Appendix B
Author	HSAG
File Modified	2017-04-14
File Created	2016-12-06