Ambulatory Surgical Center Quality Reporting (ASCQR) Program

Ambulatory Surgical Center Quality Reporting Specifications Manual
Release Notes Version: 8.0
Release Notes Completed: 05/01/2018
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 01/01/2019, 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).

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ASC Release Notes version 8.0
The notes in the tables below are organized to follow the Table of Contents in the Specifications Manual.

Measure Information Forms
Impacts: ASC-1, ASC-2, ASC-3, ASC-4
Rationale: Update to be in accordance with the latest version of the ASC Quality Collaboration
Implementation Guide.
Description of Change: Addition of new section and text
Add:
Data Sources:
ASC medical records, as well as incident/occurrence reports, and variance reports are potential data sources.
_______________________________________________________________________________________
Impacts: ASC-1, ASC-2, ASC-3, ASC-4
Rationale: Update the current Measure Information Form header to be in accordance with latest version of
the ASC Quality Collaboration Implementation Guide.
Description of Change: Change header name on Measure Information Form
From:
Selection Basis:
To:
Rationale:
_______________________________________________________________________________________
Impacts: ASC-1
Rationale: Update the current Measure Information Form header and text to be in accordance with latest
version of the ASC Quality Collaboration Implementation Guide.
Description of Change: Change header name and text on Measure Information Form
From:
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
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ASC Release Notes version 8.0
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-andpractice-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.

To:
Clinical Practice Guidelines:
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 Emergency Care Research Institute (ECRI).
_______________________________________________________________________________________
Impacts: ASC-1
Rationale: Update to be in accordance with latest version of the ASC QC Implementation Guide.
Description of Change: Replace previous reference list with new reference list
_______________________________________________________________________________________
Impacts: ASC-2
Rationale: Update the current Measure Information Form header and text to be in accordance with latest
version of the ASC Quality Collaboration Implementation Guide.
Description of Change: Change header name and text on Measure Information Form
From:
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.
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.
To:
Clinical Practice Guidelines:
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

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ASC Release Notes version 8.0
comprehensive evaluation of falls that occur; and 4) performing a post-fall revision of plan of care as
appropriate.
Frequently asked questions (FAQs) about this measure can be found in the ASC Quality Collaboration
Implementation Guide online at www.ascquality.org.
_______________________________________________________________________________________
Impacts: ASC-2
Rationale: Update to be in accordance with latest version of the ASC Quality Collaboration Implementation
Guide.
Description of Change: Replace previous reference list with new reference list
_______________________________________________________________________________________
Impacts: ASC-3
Rationale: Update the current Measure Information Form to be in accordance with latest version of the ASC
Quality Collaboration Implementation Guide.
Description of Change: Replace previous text under new header Rationale on Measure Information Form
with updated text.
From:
“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.
To:
Rationale:
“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 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 forty
professional medical associations and organizations. In order 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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ASC Release Notes version 8.0
Impacts: ASC-3
Rationale: Update the current Measure Information Form header and text to be in accordance with latest
version of the ASC QC Implementation Guide.
Description of Change: Change header name and text on Measure Information Form
From:
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
To:
Clinical Practice Guidelines:
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.
Frequently asked questions (FAQs) about this measure can be found in the ASC Quality Collaboration
Implementation Guide online at www.ascquality.org.

_______________________________________________________________________________________
Impacts: ASC-3
Rationale: Update to be in accordance with latest version of the ASC QC Implementation Guide.
Description of Change: Replace previous reference list with new reference list.
_______________________________________________________________________________________
Impacts: ASC-4
Rationale: Update the current Measure Information Form header and text to be in accordance with latest
version of the ASC QC Implementation Guide.
Description of Change: Change header name and text on Measure Information Form.
From:
Clinical Recommendation Statements:
No clinical practice guidelines specifically addressing transfers or admissions from ASCs to acute care
hospitals are available at this time.
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.
To:

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ASC Release Notes version 8.0
Clinical Practice Guidelines:
No clinical practice guidelines specifically addressing transfers or admissions from ASCs to acute care
hospitals are available at this time.
Frequently asked questions (FAQs) about this measure can be found in the ASC Quality Collaboration
Implementation Guide online at www.ascquality.org.
_______________________________________________________________________________________
Impacts: ASC-4
Rationale: Update to be in accordance with latest version of the ASC QC Implementation Guide.
Description of Change: Replace previous reference list with new reference list.
Impacts: ASC-11
Rationale: An additional clause in the measure description aligns the 2019 Measure Information Form with
2018 changes.
Description of Change:
Description:
Add: based on completing a pre-operative and post-operative visual function survey
_______________________________________________________________________________________
Impacts: ASC-11
Rationale: Changes will align 2019 Measure Information Form with 2018 changes.
Description of Change:
Numerator Statement:
Add 18 years and older
Denominator Statement:
From:
Instrument
To:
Survey
_______________________________________________________________________________________
Impacts: ASC-11
Rationale: Changes will align 2019 Measure Information Form with 2018 changes.
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ASC Release Notes version 8.0
Description of Change:
Add Definitions of performance met, not met and denominator exception by HCPCS code
_______________________________________________________________________________________
Impacts: ASC-13 and ASC-14
Rationale: Updated to be in accordance with latest version of the ASC QC Implementation Guide.
Description of Change:
Add: Rationale section to the Measure Information Form

Section 3: Quality-Data Transmission
Impacts: CSV Batch Submission File Layout
Rationale: Updated to include measures ASC-13 and ASC-14
Description of Change:
Add ASC-13 and ASC-14 to CSV file layout
Appendix B: Preview Section
Impacts: ASC-17 and ASC-18
Rationale: To include a preview of future measures
Description of Change:
Add preview of ASC-17 and ASC-18 that are finalized for the CY2022 payment determination and
subsequent years
______________________________________________________________________________________

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Ambulatory Surgical Center Quality Reporting
Specifications Manual
Version 8.0
Encounter Dates: 01-01-19 (1Q19) through 12-31-19 (4Q19)

OMB # 0938-1270 Expiration Date: 03/31/2021

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

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 .............................................................................................................................................. 1-5
ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant ....................................... 1-7
ASC-4: All Cause Hospital Transfer/Admission ................................................................................................. 1-9
ASC-8: Influenza Vaccination Coverage among Healthcare Personnel............................................................ 1-11
ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy
in Average Risk Patients ....................................................................................................................... 1-12
ASC-10: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of
Adenomatous Polyps – Avoidance of Inappropriate Use .................................................................. 1-14
ASC-11: Cataracts – Improvement in Patient’s Visual Function within 90 Days Following
Cataract Surgery................................................................................................................................. 1-16
ASC-12: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy....................... 1-18
ASC-13: Normothermia…. ................................................................................................................................ 1-24

[

ASC-14: Unplanned Anterior Vitrectomy ......................................................................................................... 1-27

[

Section 2: Quality-Data Coding & Sampling Specifications ........................................................................ 2-29
Section 3: Quality-Data Transmission .......................................................................................................... 3-30
Appendix A: Glossary of Terms .................................................................................................................... A-32
Appendix B: Preview Section..........................................................................................................................B-33

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

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 2018 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.

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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-4, 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).

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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, 2018, with claim submission on January 1, 2019, this claim would be included in the 2020
payment determination.
Claims-Based Measures
ASCs are to submit information on the four 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-9, ASC-10, ASC-11 (ASC-11 is a voluntary measure), ASC-13, and ASC-14 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.

Fewer Than 240 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 2018 (for the CY 2020 payment determination
year) would not be required to participate in the ASCQR Program in CY 2019 (for the CY 2021 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.

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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.

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

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Clinical Recommendation Statements – Supporting literature statements for the specified quality of care
measure.
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.
[Data Sources:]] ASC medical records, as well as incident/occurrence reports, and variance reports are
potential data sources.
[

]]

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
Rationale:
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 Practice Guidelines:
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.
[

]]

[

]

Selected References:
• American National Standards Institutes (ANSI) Z136.3-2011 - Safe Use of Lasers in Health Care, 2011
Revision.
• Anesthesia Patient Safety Foundation (APSF). Prevention and management of operating room fires
[video]. February 2010. http://www.apsf.org/resources/fire-safety/.
• AORN. Fire safety Tool Kit. 2015. https://www.aorn.org/guidelines/clinical-resources/tool-kits/firesafety-tool-kit.
• Apfelbaum JL, et al. Practice advisory for the prevention and management of operating room fires: an
updated report by the American Society of Anesthesiologists Task Force on Operating Room Fires.
Anesthesiology. 2013 Feb;118(2):271-90.
• 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.
• Demir E, O'Dey D, and Pallua N. Accidental burns during surgery. J Burn Care Res. 2006 ;27(6):895900.
• ECRI. Electrosurgery Checklist. February 15, 2007.
• ECRI. Higher currents, greater risks: preventing patient burns at the return-electrode site during highcurrent electrosurgical procedures. Health Devices. 2005;34(8):273-9.
• ECRI Institute. Surgical Fires. June 1, 2016.
• Jones EL, et al. Operating Room Fires and Surgical Skin Preparation. J Am Coll Surg. 2017
Jul;225(1):160-165.
• Jones SB, et al. Fundamental Use of Surgical Energy (FUSE): An Essential Educational Program for
Operating Room Safety. Perm J. 2017;21. pii: 16-050.
• Mehta SP, Bhananker SM, Posner KL, Domino KB. Operating room fires: a closed claims analysis.
Anesthesiology. 2013 May;118(5):1133-9.
• National Fire Protection Association (NFPA). NFPA 99: Health Care Facilities Code. Quincy, MA:
NFPA, 2018.
• Tucker R. Laparoscopic electrosurgical injuries: survey results and their implications. Surg Laparosc
Endosc. 1995;5(4):311-7.

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

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.
Data Sources: ASC medical records, as well as incident/occurrence reports, and variance reports are
potential data sources.
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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)
Rationale:
“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.
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Clinical Practice Guidelines:
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
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comprehensive evaluation of falls that occur; and 4) performing a post-fall revision of plan of care as
appropriate.
Frequently asked questions (FAQs) about this measure can be found in the ASC Quality Collaboration
Implementation Guide online at www.ascquality.org.
[

]

Selected References:
Amador LF, Loera JA. Preventing Postoperative Falls in the Older Adult. J. Am. Coll. Surg. 3// 2007;
204(3):447-453.
American Geriatrics Society/British Geriatrics Society Panel on Prevention of Falls in Older Persons.
Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline
for Prevention of Falls in Older Persons. J.Am. Geriatr. Soc. 2011;59(1):148-157.
American Medical Directors Association (AMDA). Falls and fall risk. Columbia, MD: American Medical
Directors Association.
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.
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.
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.
The Joint Commission. Sentinel Event Alert 55: Preventing falls and fall-related injuries in health care
facilities. September 28, 2015.
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 2011 Update. 2011.
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.
(Please note this is not intended to be an exhaustive list of the organizations issuing statements or guidance
related to falls.)

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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.
Data Sources: ASC medical records, as well as incident/occurrence reports, and variance reports are
potential data sources.
[

]

Definitions:
• Admission – Completion of registration upon entry into the facility
• Wrong – Not in accordance with intended site, side, patient, procedure, or implant
Rationale:
“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 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 forty
professional medical associations and organizations. In order 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 Practice Guidelines:
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.
[

]

Frequently asked questions (FAQs) about this measure can be found in the ASC Quality Collaboration
Implementation Guide online at www.ascquality.org.
[

]

Selected References:
American Academy of Ophthalmology. Recommendations of American Academy of Ophthalmology
Wrong-Site Task Force. http://www.aao.org/Assets/c85186a8-5f17-422b-861efd4e4b061dff/635518426969930000/revisedwswiol-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. Statement on ensuring correct patient, correct site, and correct procedure
surgery. October 1, 2016 https://www.facs.org/about-acs/statements/93-surgery-checklists.
AORN. AORN Position Statement on Preventing Wrong-Patient, Wrong-Site, Wrong-Procedure Events.
https://www.aorn.org/guidelines/clinical-resources/position-statements
Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National
Academy Press, 2000.
The Joint Commission. Universal Protocol For Preventing Wrong Site, Wrong Procedure, Wrong Person
Surgery. Available at: http://www.jointcommission.org/standards_information/up.aspx. Last accessed
December 14, 2010.
National Quality Forum. Serious Reportable Events in Healthcare – 2011 Update: A Consensus Report.
2011.
World Health Organization. WHO Guidelines for Safe Surgery 2009.
http://apps.who.int/iris/bitstream/10665/44185/1/9789241598552_eng.pdf.

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.

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

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.
Data Sources: ASC medical records, incident/occurrence reports and variance reports are potential data
sources.
[

]

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
Rationale:
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.
[

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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.
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Clinical Practice Guidelines:
No clinical practice guidelines specifically addressing transfers or admissions from ASCs to acute care
hospitals are available at this time.
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Frequently asked questions (FAQs) about this measure can be found in the ASC Quality Collaboration
Implementation Guide online 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.
Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery—a prospective study. Can J
Anaesth. 1998 Jul;45(7):612-9.
Fox JP, Vashi AA, Ross JS, Gross CP. Hospital-based, acute care after ambulatory surgery center discharge.
Surgery. 2014 May;155(5):743-53.
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.
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.
Lau H, Brooks DC. Predictive factors for unanticipated admissions after ambulatory laparoscopic
cholecystectomy. Arch Surg. 2001 Oct;136(10):1150-3.
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.
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.
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.
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.
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.

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

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.,inadequate prep, familial or personal history of colonic polyps, patient had no adenoma and age is
≥66 years old, or life expectancy <10 years, other medical reasons). 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 ≥66 years old, or life expectancy
<10 years. Documentation of a medical condition or finding can be used as a medical reason(s) for
denominator exclusion purposes only if the documented recommended follow-up 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.
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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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Material inside brackets ([and]) is new to this Specifications Manual version.

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,based on completing a preoperative and post-operative visual function survey
[

]

Numerator Statement: Patients 18 years and older 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 survey
[

]

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.
Definition of Performance Met: Improvement in visual function achieved within 90 days following cataract
surgery (G0913)
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Definition of Performance Not Met: Improvement in visual function not achieved within 90 days following
cataract surgery (G0915)
[

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Denominator Exception: Patient care survey was not completed by patient (G0914)

[

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

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), the 2016 Measure Updates and Specifications Report
https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid
=1228775214597 and the 2017 Measure Updates and Specifications Report
(https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&ci
d=1228775197506). 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 2017 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 2017 Measure Updates and Specifications Report contains complete coding for all exclusions.
[Note: The codes in Table 1 have been modified to replace the last letter X with an asterisk*]

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

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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

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. at the flowchart and tables are available in the 2017 Measure Updates
and
Specifications Report, located at
https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid
=1228775197506
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 2017 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

Risk-adjusted 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
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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 Specificatio ns Manual version.

Measure Information Form
Measure Title: Normothermia
Measure ID #: ASC-13
Quality Reporting Option: Measure submitted via a web-based tool
Description: This measure is used to assess the percentage of patients having surgical procedures under
general or neuraxial anesthesia of 60 minutes or more in duration are normothermic within 15 minutes of
arrival in PACU.
Numerator: Surgery patients with a body temperature equal to or greater than 96.8 Fahrenheit/36 Celsius
recorded within fifteen minutes of Arrival in PACU
Denominator: All patients, regardless of age, undergoing surgical procedures under general or neuraxial
anesthesia of greater than or equal to 60 minutes duration
Numerator Exclusions: None
Denominator Exclusions: Patients who did not have general or neuraxial anesthesia; patients whose length
of anesthesia was less than 60 minutes; patients with physician/APN/PA documentation of intentional
hypothermia for the procedure performed
Data Sources: ASC medical records, as well as anesthesia administration and nursing records may serve as
data sources. Clinical logs designed to capture information relevant to normothermia are also potential
sources.
Data Element Definitions:
Anesthesia duration: the difference, in minutes, between the time associated with the start of anesthesia for
the principal procedure and the time associated with the end of anesthesia for the principal procedure
Arrival in PACU: Time of patient arrival in PACU*
General anesthesia: drug-induced loss of consciousness during which the patient is not arousable, even by
painful stimulation
Intentional hypothermia: A deliberate, documented effort to lower the patient's body temperature in the
perioperative period
Neuraxial anesthesia: Epidural or spinal anesthesia
Temperature: A measure in either Fahrenheit or Celsius of the warmth of a patient's body. Axillary, bladder,
core, esophageal, oral, rectal, skin surface, temporal artery, or tympanic temperature measurements may be
used.
* Definition of Arrival in PACU is consistent with the definition in the Procedural Times Glossary of the American Association of Clinical Directors as approved
by the ASA, ACS and AORN.

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Rationale:
Impairment of thermoregulatory control due to anesthesia may result in perioperative hypothermia.
Hypothermia, even when mild, is associated with consequences such as increased susceptibility to infection,
impaired coagulation, cardiovascular stress and cardiac complications, as well as post-anesthetic shivering
and thermal discomfort. Several methods to maintain normothermia are available.
[

]

[

]

There is no literature available on variation in rates of normothermia among ASC providers. However,
variability in maintaining normothermia has been demonstrated in other settings.
[

]

Clinical Practice Guidelines:
This performance measure is aligned with current guidelines regarding temperature management in patients
undergoing general or neuraxial anesthesia lasting 60 minutes or more.
Measure ascertains response to the following question: What is the percentage of having surgical
procedures under general or neuraxial anesthesia of 60 minutes or more in duration are normothermic within
15 minutes of arrival in PACU?
Annual data submission period: January 1-May 15, 2020
References
American Society of PeriAnesthesia Nurses (ASPAN). ASPAN’s evidence-based clinical practice guideline
for the promotion of perioperative normothermia: second edition. J Perianesth Nurs. 2010;25(6):346-65.
Anderson DJ et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect
Control Hosp Epidemiol. 2014;35 Suppl 2: S66-88.
Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB,
Kasper EK, Kersten JR, Riegel B, Robb JF. ACC/AHA 2007 guidelines on perioperative cardiovascular
evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on
Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 2007;50: e159 –241.
Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative maintenance of normothermia reduces the
incidence of morbid cardiac events. A randomized clinical trial. JAMA. 1997;277(14): 1127-1134.
Frank SM, Beattie C, Christopherson R, et al. Unintentional hypothermia is associated with postoperative
myocardial ischemia. The Perioperative Ischemia Randomized Anesthesia Trial Study Group.
Anesthesiology. 1993;78(3):468-476.
Kurz A. Physiology of thermoregulation. Best Pract Res Clin Anaesthesiol. 2008;22(4):627-644.
Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound
infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med.
1996;334(19):1209- The quality measures presented in this guide are the intellectual property of the ASC
Quality Collaboration. 14 1215.
Kurz A, Sessler DI, Schroeder M, Kurz M. Thermoregulatory response thresholds during spinal anesthesia.
Anesth Analg. 1993;77(4):721-726.
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Lista F, Doherty CD, Backstein RM, Ahmad J. The impact of perioperative warming in an outpatient
aesthetic surgery setting. Aesthet Surg J. 2012 Jul;32(5):613-20.
Matsukawa T, Sessler DI, Sessler AM, et al. Heat flow and distribution during induction of general
anesthesia. Anesthesiology. 1995;82(3):662-673.
Morris RH. Operating room temperature and the anesthetized, paralyzed patient. Arch Surg. 1971;102(2):9597.
Ozaki M, Kurz A, Sessler DI, et al. Thermoregulatory thresholds during epidural and spinal anesthesia.
Anesthesiology. 1994;81(2):282-288.
Rajagopalan S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hypothermia on blood loss and
transfusion requirement. Anesthesiology. 2008;108(1):71-77.
Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A. Mild hypothermia increases blood loss and transfusion
requirements during total hip arthroplasty. Lancet. 1996;347(8997):289-292.
Scott EM, Buckland R. A systematic review of intraoperative warming to prevent postoperative
complications. AORN J. 2006;83(5):1090-1104, 1107-1113.

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Measure Information Form
Measure Title: Unplanned Anterior Vitrectomy
Measure ID #: ASC-14
Quality Reporting Option: Measure submitted via a web-based tool
Description: This measure is used to assess the percentage of cataract surgery patients who have an
unplanned anterior vitrectomy.
Numerator: All cataract surgery patients who had an unplanned anterior vitrectomy
Denominator: All cataract surgery patients
Numerator Exclusions: None
Denominator Exclusions: None
Data Sources:
ASC medical records, incident/occurrence reports and variance reports are potential data sources
Definitions:
Cataract surgery: for purposes of this measure, CPT code 66982 (Cataract surgery, complex), CPT code
66983 (Cataract surgery w/IOL, 1 stage) and CPT code 66984 (Cataract surgery w/IOL, 1 stage)
Unplanned anterior vitrectomy: an anterior vitrectomy that was not scheduled at the time of the patient's
admission to the ASC
[Rationale: The need for unplanned anterior vitrectomy is an unanticipated event that can decrease the
probability of good postoperative visual acuity, and generally result in worse long-term outcome after
cataract surgery. Because cataract surgery is the most common surgery performed in ASCs, with millions
being performed every year, even low unplanned anterior vitrectomy rates translate to relatively high total
numbers of affected patients. ASCs can help keep rates low by tracking and comparing rates to established
benchmarks, and facilitating mentoring as needed.]
Clinical Practice Guidelines: No clinical practice guidelines addressing unplanned anterior vitrectomy in
cataract surgery are available at this time. However, rates of unplanned anterior vitrectomy have been
published in the clinical literature and can serve as comparative benchmarks of performance.
Measure ascertains response to the following question: What is the percentage of cataract surgery patients
who have an unplanned anterior vitrectomy?
Annual data submission period: January 1-May 15, 2020
References
American Academy of Ophthalmology Cataract and Anterior Segment Panel. Preferred Practice Pattern®
Guidelines. Cataract in the Adult Eye. San Francisco, CA: American Academy of Ophthalmology; 2011.

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Chen M, Lamattina KC, Patrianakos T, Dwarakanathan S. Complication rate of posterior capsule rupture
with vitreous loss during phacoemulsification at a Hawaiian cataract surgical center: a clinical audit. Clin
Ophthalmol. 2014 Feb 5;8: 375-8.
Johansson B, Lundström M, Montan P, Stenevi U, Behndig A. Capsule complication during cataract surgery:
Longterm outcomes: Swedish Capsule Rupture Study Group report 3. J Cataract Refract Surg. 2009
Oct;35(10):1694-8.
Lum F, Schein O, Schachat AP, et al. Initial two years of experience with the AAO National Eyecare
Outcomes Network (NEON) cataract surgery database. Ophthalmology 2000; 107:691-7.
Powe NR, Schein OD, Gieser SC, et al, Cataract Patient Outcome Research Team. Synthesis of the literature
on visual acuity and complications following cataract extraction with intraocular lens implantation. Arch
Ophthalmol 1994; 112:239-52.
Schein OD, Steinberg EP, Javitt JC, et al. Variation in cataract surgery practice and clinical outcomes.
Ophthalmology 1994; 101:1142-52.
Tan JH, Karwatowski WS. Phacoemulsification cataract surgery and unplanned anterior vitrectomy--is it bad
news? Eye (Lond). 2002 Mar;16(2):117-20.
Zaidi FH, Corbett MC, Burton BJ, Bloom PA. Raising the benchmark for the 21st century--the 1000 cataract
operations audit and survey: outcomes, consultant-supervised training and sourcing NHS choice. Br J
Ophthalmol 2007; 91: 731-6.

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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 the four 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.
For more information on measures ASC-1–ASC-4, see individual measure specifications in this manual.
ASC-9, ASC-10, ASC-11*, and ASC-13  The sampling size specifications for ASC-9, ASC-10, ASC-11*,
and ASC-13 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, or Normothermia (ASC-13). **
Population Per Year

0-900

Yearly Sample Size

63

Quarterly Sample Size

16

Monthly Sample Size

6

Population Per Year

≥ 901

Yearly Sample Size

96

Quarterly Sample Size

24

Monthly Sample Size

8

*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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Quality Data Transmission
Introduction
This section of the manual is provided to highlight the unique data transmission specifications for the
Ambulatory Surgical Center measure data for the Centers for Medicare & Medicaid Services (CMS) and the
CMS Clinical Data Warehouse.
Guidelines for Submission of Data
Data collected for CMS are transmitted to the CMS Clinical Data Warehouse. All data submitted are
required to meet transmission requirements. The file layout requirements are included in this section.
Ambulatory Surgical Center Web-Based Measure Batch Submission File Layout
The Comma-Separated Value (CSV) file layout is one section of content with rows defining unique facilities
and columns defining measure data. Please refer to the Ambulatory Surgical Center Web-Based Batch
Submission file layout for an example and details of required fields.
ASC_PROVIDER_NPI – National Provider ID
ASC_PYR – Payment Year
ASC_9_POP_SIZE – What was your facility’s Total population?
ASC_9_SAMP_SIZE – What was your facility’s sample size?
ASC_9_SAMP_FREQ – What was your facility’s sampling frequency?
ASC_9_NUMERATOR – Patients who have a recommended follow-up interval of at least 10 years
for repeat colonoscopy documented in their colonoscopy report.
ASC_9_DENOMINATOR – All patients aged 50 years and older receiving screening colonoscopy
without biopsy or polypectomy.
ASC_10_POP_SIZE – What was your facility’s Total Population?
ASC_10_SAMP_SIZE – What was your facility’s sample size?
ASC_10_SAMP_FREQ – What was your facility’s sampling frequency?
ASC_10_NUMERATOR – Patients who had an interval of 3 or more years since their last
colonoscopy.
ASC_10_DENOMINATOR – All patients 18 years and older receiving a surveillance colonoscopy
with a diagnosis for history of colonic polyp(s).
ASC_11_POP_SIZE – What was your facility’s Total Population?
ASC_11_SAMP_SIZE – What was your facility’s sample size?
ASC_11_SAMP_FREQ – What was your facility’s sampling frequency?
ASC_11_NUMERATOR – Patients who had an improvement in visual function achieved within 90
days following cataract surgery, based on completing both a pre-operative and post-operative visual
function instrument.
ASC_11_DENOMINATOR – All patients 18 years and older who had cataract surgery and
completed both a pre-operative and post-operative visual function instrument.
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ASC_13_POP_SIZE – What was your facility’s Total Population?
ASC_13_SAMP_SIZE – What was your facility’s sample size?
ASC_13_SAMP_FREQ – What was your facility’s sampling frequency?
ASC_13_NUMERATOR – Surgery patients with a body temperature equal to or greater than 96.8
Fahrenheit/36 Celsius recorded within fifteen minutes of Arrival in PACU.
ASC_13_DENOMINATOR – All patients, regardless of age, undergoing surgical procedures under
general or neuraxial anesthesia of greater than or equal to 60 minutes duration.
ASC_14_NUMERATOR – All cataract surgery patients who had an unplanned anterior vitrectomy.
ASC_14_DENOMINATOR – All cataract surgery patients.
Data Upload Process
Data upload is done through the QualityNet External Files Online Tool.
All data transmitted pass through the following process:
1. The file(s) are checked for proper naming convention and file type.
• The correct file naming convention is ASC_WBM_PY20YY_mm_dd_yyyy.csv where YY
represent the last two digits of the applicable Payment Year, and mm_dd_yyyy represents the
upload date.
2. The file(s) are evaluated upon successful upload and checked for errors in content.
a. The system sends an upload confirmation email to the registered email for the logged-in
account.
b. The system checks the file for errors, logging each error in the file, and then rejects the file if
any errors are found. The error log is attached to the rejection notification email with one
error per line.
c. If no errors are found, the system uploads the file and applies the data to the given Payment
Year.
3. Note that there is no ADD, UPDATE, or DELETE action-code associated with the file. To correct
errors, you can either:
•
•

Enter the Web-Based Data Collection Tool for each individual facility and update the values as
appropriate, or
Upload a corrected CSV file which will overwrite any existing values.

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Appendix A: Glossary of Terms
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.
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.
Order: A written order, verbal order, standing order, or standing protocol.
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.

ASCQR Specifications Manual
Encounter dates 01-01-19 (1Q19) through 12-31-19 (4Q19) v8.0
CPT® only copyright 2018 American Medical Association. All rights reserved.

Appendix A-32

All content on this page is new to this

Appendix B: Preview Section

The Preview Section provides information on new measures.
The measures below were finalized in the ASCQR Program for the CY 2022 payment determination and
subsequent years per the Final Rule: https://www.gpo.gov/fdsys/pkg/FR-2017-11-13/pdf/2017-23932.pdf
(pp. 52564-52637).
ASC-17: Hospital Visits After Orthopedic Ambulatory Surgical Center Procedures
Measure Background and Overview:
“The patient population served at ASCs has increased not only in volume, but also in age and complexity,
which can be partially attributed to improvements in anesthetic care and innovations in minimally invasive
surgical techniques. As such, ASCs have become the preferred setting for the provision of low-risk surgical
and medical procedures in the United States, as many patients experience shorter wait times, prefer to avoid
hospitalization, and are able to return to work more quickly. As the number of orthopedic procedures
performed in ASCs increases, it is increasingly important to report the quality of care for patients undergoing
these procedures.” (82FR52595)
“Based on the increasing prevalence of orthopedic surgery in the ASC setting, we believe it is important to
minimize adverse patient outcomes associated with these orthopedic ASC surgeries. Therefore, in the CY
2018 OPPS/ASC proposed rule (82 FR 33692), we proposed to adopt the ASC–17: Hospital Visits after
Orthopedic Ambulatory Surgical Center Procedures measure into the ASCQR Program for the CY 2022
payment determination and subsequent years.” (82FR52595)
Measure Calculation and Reporting:
“The measure outcome is all-cause, unplanned hospital visits within seven days of an orthopedic procedure
performed at an ASC. For the purposes of this measure, ‘‘hospital visits’’ include emergency department
visits, observation stays, and unplanned inpatient admissions. When there are two or more qualifying
surgical procedures within a 7-day period, the measure considers all procedures as index procedures;
however, the timeframe for outcome assessment is defined as the interval between procedures (including the
day of the next procedure) and then 7 days after the last procedure. The facility-level score is a risk
standardized hospital visit rate, calculated by multiplying the ratio of the predicted to the expected number of
post-surgical hospital visits among the given ASC’s patients by the national observed hospital visit rate for
all ASCs. For each ASC, the numerator of the ratio is the number of hospital visits predicted for the ASC’s
patients accounting for its observed rate, the number of the orthopedic surgeries performed at the ASC, the
case-mix, and the surgical complexity mix. The denominator of the ratio is the expected number of hospital
visits given the ASC’s case-mix and surgical complexity mix. A ratio of less than one indicates the ASC
facility’s patients were estimated as having fewer post-surgical visits than expected compared to ASCs
with similar surgical complexity and patients; and a ratio of greater than one indicates the ASC facility’s
patients were estimated as having more visits than expected. The national observed hospital visit rate is the
national unadjusted proportion of patients who had a hospital visit following an orthopedic ASC surgery.”
(82FR52597)
“The data collection period for the proposed ASC–17: Hospital Visits after Orthopedic Ambulatory Surgical
Center Procedures measure would be the two calendar years ending two years prior to the applicable
payment determination year. For example, for the CY 2022 payment determination, the data collection

ASCQR Specifications Manual
Encounter dates 01-01-19 (1Q19) through 12-31-19 (4Q19) v8.0
CPT® only copyright 2018 American Medical Association. All rights reserved.

Appendix B-33

period would be CY 2019 to 2020. Because the measure data are collected via claims, ASCs will not
need to submit any additional data directly to CMS.” (82FR52596)
ASC-18: Hospital Visits After Urology Ambulatory Surgical Center Procedures
Measure Background and Overview:
“Because urology surgery performed at an ASC is a significant predictive factor for unanticipated
admissions compared to other procedures, we believe measuring and reporting 7-day unplanned hospital
visits following urology procedures will incentivize ASCs to improve care and care transitions. Many of the
reasons for hospital visits following surgery at an ASC are preventable; patients often present to the hospital
following urology surgery for complications of medical care, including urinary tract infection, calculus of the
ureter, urinary retention, hematuria, and septicemia. However, increased patient and staff education present
opportunities to improve the success rate of urology surgeries in ASCs. Therefore, we believe tracking and
reporting these events would facilitate efforts to lower the rate of preventable adverse events and to improve
the quality of care following urology procedures performed at an ASC.” (82FR52603)
“We believe it is important to minimize adverse patient outcomes associated with urology ASC surgeries.
Therefore, in the CY 2018 OPPS/ASC proposed rule (82 FR 33695), we proposed to adopt the ASC–18:
Hospital Visits after Urology Ambulatory Surgical Center Procedures measure in the ASCQR Program for
the CY 2022 payment determination and subsequent years.” (82FR52603)
Measure Calculation and Reporting:
“The measure outcome is all-cause, unplanned hospital visit occurring within seven days of the urology
procedure performed at an ASC. For the purpose of this measure, ‘‘hospital visits’’ include emergency
department visits, observation stays, and unplanned inpatient admissions. When there are two or more
qualifying surgical procedures within a 7-day period, the measure considers all procedures as index
procedures. However, the timeframe for outcome assessment is defined as the interval between procedures
(including the day of the next procedure) and then 7 days after the last procedure. The facility-level score is a
risk standardized hospital visit rate, calculated by multiplying the ratio of the predicted to the expected
number of postsurgical hospital visits among the given ASC’s patients by the national observed hospital visit
rate for all ASCs. For each ASC, the numerator of the ratio is the number of hospital visits predicted for the
ASC’s patients accounting for its observed rate, the number of the urology procedures performed at the
ASCs, the case-mix, and the surgical complexity mix. The denominator of the ratio is the expected number
of hospital visits given the ASC’s case-mix and surgical complexity mix. A ratio of less than one indicates
the ASC facility’s patients were estimated as having fewer post-surgical visits than expected compared to
ASCs with similar surgical complexity and patients; and a ratio of greater than one indicates the ASC
facility’s patients were estimated as having more visits than expected. The national observed hospital visit
rate is the national unadjusted proportion of patients who had a hospital visit following a urology ASC
surgery.” (82FR52604)
“The data collection period for the proposed ASC–18: Hospital Visits after Urology Ambulatory Surgical
Center Procedures measure would be the 2 calendar years ending 2 years prior to the applicable payment
determination year. For example, for the CY 2022 payment determination, the data collection period would
be CY 2019 to 2020. Because these measure data are collected via claims, ASCs will not need to submit
any additional data directly to CMS.” (82FR52604)

ASCQR Specifications Manual
Encounter dates 01-01-19 (1Q19) through 12-31-19 (4Q19) v8.0
CPT® only copyright 2018 American Medical Association. All rights reserved.

Appendix B-34