1. ASC Quality Measure Reporting Ann Shimek, MSN, RN, CASC Senior Vice President Clinical Operations United Surgical Partners International

2. Objectives Access and use the Specifications Manual Describe Claims Based, Structural and Web- Based Measure Reporting method Understand Reporting Periods versus Payment Periods Enroll in the QualityNet Portal Describe the method for reporting ASC – 9 and ASC – 10 Manual Abstraction – ASC 9 and ASC 10 Enroll in the National Safety Health Network (NHSN) Define Influenza Vaccination measure 2

3. Access & Use the Specifications Manual The Specifications Manual is the comprehensive manual that describes the criteria for measure collection and reporting for all of the quality reporting measures To access go to www.qualitynet.com 3

4. www.qualitynet.org 4

5. Hover mouse over Ambulatory Surgery Tab Click on Specifications Manual Select most recent manual 5

6. Click on the version desired to open 6

7. Using the Specifications Manual Table of Contents - each measure by number Locate measure desired by page Quality Reporting Option Claims-based or Web- based Claims-based G-code billed if event occurred Web-based Data are manually entered into a web based computer system (includes Structural Measures) Inclusion Criteria – patients and cases that should be included in the denominator Exclusion Criteria – patients or cases, if any, that should not be included in the measure denominator 7

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9. Claims-Based Measures Reported by using ‘G’ codes when the record is billed ASC-1 Patient burns ASC-2 Patient Fall ASC-3 Wrong Site Surgery ASC-4 Hospital Transfer / Admission ASC-5 Prophylactic Antibiotic Timing These measures are on-going and nothing has changed since we started reporting in 2012 9

10. Claims-Based Reporting & Payment Periods Data Submission Ongoing 10

11. Structural Measures A type of web-based measure that results in answering yes or no questions or entering volume data ASC – 6 Safe Surgery Checklist Use ASC – 7 Surgical Volume Data Same measures as last year but CMS reset reporting period Will enter data from January 1, 2015 – August 15, 2015 11

12. Structural Reporting & Payment Periods 12

13. Web-Based Measures Web-based Measures (include Structural Measures) are reported by accessing and entering data into the QualityNet Portal or NHSN websites. ASC-6 Safe Surgery Checklist - QualityNet Portal ASC-7 Facility Volume Data – QualityNet Portal New measures added this year are the following: ASC-8 Influenza Vaccination - NHSN ASC-9 Endo Ten Year Statement – QualityNet Portal ASC-10 Endo > 3 year - QualityNet Portal ASC-11 (Cataract – On Hold) 13

14. Web-Based Reporting & Payment Periods 14

15. QualityNet Portal Requires two individuals with access to the portal at all times AKA QualityNet Administrators Facilities must replace QualityNet Administrators as soon as possible if one or both leave employment QualityNet Administrators must ‘sign up’ and complete a registration process Signing up can take several weeks to complete To begin go to www.qualitynet.org 15

16. www.qualitynet.org To Register 16

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18. Print Security Administrator Responsibilities and Follow Instructions 18

19. Receive E-Mail with User ID/Password then log in 19

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21. PressPress 21

22. Pressing Submit will take the registrar to the next tab for completion until registration is complete 22

23. Describe Reporting ASC - 9 & ASC - 10 Must increase monthly and quarterly samples to meet annual sample 23

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26. Follow-up recommendation must be documented in the final dictated report and may not be abstracted from any other document in the record. An Exclusion to the measure denominator means that the statement is not required and the chart does not need to be abstracted Statement must be ‘follow up in 10 years’ or any timeframe longer than 10 years. Cannot take credit for the 10 year statement being present if the statement says ‘follow up in 5-10 years’ because this timeframe includes a timeframe that is less than 10 years. Cannot assume reasons why the follow-up recommendation was a timeframe other than 10 years or longer. Documentation of why the recommendation was different than the expected follow up timeframe must exist. Important Points ASC - 9 26

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29. CMS will use date collected in record to determine if today’s colonoscopy was less than three years from the last. (mm/dd/year) (mm/year) (year). Cannot assume why today’s colonoscopy is being performed less than three years from the last – reason must be documented. Important Points ASC - 10 29

30. http://www.oqrsupport.com/media/tools/ASC_Endoscopy _and_Polyp_Surveillance_Tool_FINAL_update_508.pdf 30

31. Manual Abstraction ASC-9 and ASC- 10 Abstraction means the same thing as completing a focus study or audit tool Abstractors answer specific questions Questions are answered according to ‘rules’ Abstraction will be needed for April through December 2014 and will be reported in the QualityNet Portal in 2015 – reminders will be made. 31

32. ASC-9 Documented in the final dictated colonoscopy report recommended follow-up of at least 10 years for normal screening colonoscopy in low to average risk patient without biopsy or polypectomy. Patient population age 50 and over. 32

33. Endoscopy Core Measures Obtain report from patient accounting system with list of patient names that fall into each measure respectively from April 1, 2014 – December 32, 2014 Business office can run based on CPT codes Choose the appropriate sample following the guidelines we will discuss on later slides Abstract the appropriate number of records each month Calculate Numerators and Denominators monthly and annually 33

34. Endoscopy Core Measures ASC - 9 34

35. ASC-10 Surveillance colonoscopy being performed 3 or greater years from last colonoscopy OR must contain documentation of specific allowable reasons why the colonoscopy is being performed sooner in patients 18 years old or older 35

36. Endoscopy Core Measures ASC - 10 36

37. Sample Size Requirements Select a sample by pulling the correct number of charts you need to abstract per month < 63 cases annually Abstract 100% of the cases that fall into both ASC-9 and ASC-10. In other words, you will abstract all of the patients on the list No random sample required due to 100% abstraction 63-900 Colonoscopies Annually Abstract 7 charts a month from April-December 2014 for each ASC-9 and ASC-10 37

38. Sample Size Requirements (continued) ≤ 901 colonoscopies annually Abstract 11 charts per month from April-December 2014 for each ASC-9 and ASC-10 There may be times when abstraction results in the case pulled being EXCLUDED from the measure If this happens another number will need to be pulled from a container and another and another patient chart from the list chosen to take the place of the EXCLUDED record 38

39. Calculate Monthly and Annual Numerator and Denominator Each month count the number of Numerator Inclusions and the total number of Included forms Do not count any exclusions!!! Add up total numerators and denominators from April through December and that is what you will data enter into QualityNet 39

40. Enroll in NHSN Go to: http://www.cdc.gov/nhsn/ambulatory- surgery/enroll.html Complete EVERY step beginning with Step 1 and ending with Step 5 40

41. 5 Step Overview 41

42. After Step 5 Use the purple highlighted link at the top of the NHSN page (shown above Step 1) to learn about the Immunization Requirements and for specific guidance on data entry into NHSN 42

43. Describe Influenza Reporting 43

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46. http://www.cdc.gov/nhsn/PDFs/HPS-manual/vaccination/HPS-flu- vaccine-protocol.pdf 46

47. Thank You! 47