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Since October 1, 2012, ASCs have been required to report quality data codes (QDCs) for five measures on at least 50 percent of Medicare claims, or face Medicare payment reductions of 2 percent. Although ASCs now have this new process in place, some questions and misconceptions remain about aspects of the quality measures still to come. To help facilities get a handle on these new reporting requirements and avoid future financial penalties associated with non-compliance, outlined below are four questions that the SourceMedical team has been hearing over the past several months, with some key points to answer these concerns.
What is required of my facility under the safe-surgery check list measure (ASC-6)?
Between July 1 and August 15, 2013, ASCs participating in the program are required to go to the CMS QualityNet website and report whether they used a safe-surgery checklist at any point during the 2012 calendar year. The safe-surgery checklist applies to all patients, not just those covered by Medicare.
When a facility attests to following a safe-surgery checklist, they are saying that, during 2012, it was the facility’s standard operating procedure to use the check list during the following phases of care: pre-anesthesia, prior to incision and at incision-close time before the patient is removed from the OR. To attest to this measure, your facility will need to identify the individual who will act as your QualityNet security administrator. Once registered with QualityNet, the QualityNet administrator will simply confirm that a safe-surgery checklist was in use at the facility during 2012 (use during part of the year counts as compliant with the measure). There is no case-by-case confirmation of use; this measure is a one-shot deal for 2012.
While the QualityNet site provides examples of safe-surgery checklists, these lists serve only as suggested lists. Facilities are not required to use a specific checklist at this time, so long as the content reflects accepted standards of care. Furthermore, while including a safe-surgery checklist in each patient’s chart is considered a best practice, it is not mandatory under the program. Facilities have the option of other approaches, such as displaying the checklist on OR / procedure room walls where it is clear and visible.
How will my facility report the procedure volume data required to meet measure ASC-7? What are the specifics?
Like ASC-6, ASC-7 (ASC Facility Volume Data on Selected ASC Surgical Procedures) is a structural measure and is reported via QualityNet. Like the safe-surgery checklist measure, the reporting period is the 2012 calendar year, and the data will be submitted between July 1, 2013 and August 15, 2013. If your facility has a “zero” count for a certain procedure code, you will report that as part of the process.
In December, 2012, the Quality Measures Manual (available on QualityNet) was updated. Included in this update were changes to the procedure codes tracked as part of the Cardiovascular Organ system. Four codes were removed, and 13 were added. Be sure that your software or other method of calculating the procedure count has been updated to reflect this change.
Are all of the upcoming quality measures done through QualityNet?
No. While safe-surgery checklist (ASC-6) and procedural-volume reporting (ASC-7) will be reported via QualityNet, flu vaccination among workers (ASC-8) will be reported to the National Healthcare Safety Network. More specifics on reporting logistics are expected soon, according to CMS.
What happens if my facility misses a deadline?
If a facility misses a reporting date or threshold there is no “do over.” While there is a reconsideration process, it is not intended to be used for routine failures to meet a date or threshold. There is a separate category for unusual circumstances, such as natural disasters, that may affect a facility and its systems, making it impossible to meet a deadline. Facilities will be given an opportunity to prove why they were unable to meet a date or requirement in such situations.
Missed dates and inaccurate information can be especially costly in this program. For this reason, facility-wide staff training is very important to ensure that all employees understand the importance of quality reporting, what is expected of them, and the repercussions associated with submitting inaccurate information or missing deadlines.
Technology will play a key role in achieving compliance and in substantiating the data you submit with specifics in the event of an audit. The ability to electronically document your safe-surgery checklist use, flu vaccination of workers, procedure volumes, and the claims-based measures is a good practice. Look for software that can help your staff automate wherever it is reasonable, while keeping in mind that too much automation can be seen as suspect in an audit. Examples of helpful features include: the ability for QDCs to be automatically generated based on clinical documentation, automated task creation when a QDC needs further review, system reminders for upcoming worker vaccinations and reporting tools that allow you to track your facility’s progress on quality measures during the course of the reporting period.
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