Has anyone heard anymore information on this?? Or what as coders are we suppose to do?
Centers for Medicare & Medicaid Services
Ambulatory Surgical Center
Quality Reporting Program
Quality Measures
Specifications Manual
Version 1.0
April 2012
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program i
TABLE OF CONTENTS
BACKGROUND .................................................................................................................... 1
THE SPECIFICATIONS MANUAL ....................................................................................... 3
Ambulatory Surgical Center (ASC) Quality Reporting Measures ........................................... 5
Patient Burn ............................................................................................................................... 5
Patient Fall ................................................................................................................................ 8
Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant .......................... 10
Hospital Transfer/Admission .................................................................................................... 12
Prophylactic Intravenous (IV) Antibiotic Timing ........................................................................ 14
ASC Facility Volume Data on Selected ASC Surgical Procedures .......................................... 17
Safe Surgery Checklist Use ..................................................................................................... 19
APPENDIX A: DATA DEFINITIONS ................................................................................. 20
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 1
BACKGROUND
Quality Reporting for Ambulatory Surgical Centers
Welcome to quality reporting for Ambulatory Surgical Centers (ASCs)! This manual provides
specifications for quality measures finalized for reporting to meet requirements for this recently
finalized program.
A quality reporting program for ASCs was finalized by the Centers for Medicare and Medicaid
Services (CMS) in the Calendar Year (CY) 2012 OPPS/ASC Final Rule with Comment Period
(CMS-1525-FC). Five claims-based measures (four outcome measures and one process of care
measure) were adopted for the CY 2014 payment determination. For the CY 2015 payment
determination, the same claims-based measures and two structural measures (surgical procedure
volume and safe surgery checklist use) were adopted for a total of seven quality measures. For the
CY 2016 payment determination, the same claims-based and structural measures as adopted for
the CY 2015 payment determination and one process of care measure were adopted.
ASCs that do not meet program requirements for ASC Quality Reporting may receive a 2 percent
reduction in their ASC annual payment update. Thus, only separately identifiable entities certified
as ASC by Medicare are affected by program requirements and possible payment penalty under
the ASC Quality Reporting Program. The definition of an ASC can be found in the Claims
Processing Manual, Chapter 14, Section 10.1 located on the CMS website (www.cms.hhs.gov).
The below table summarizes the quality measures, reporting periods, and payment years affected.
Table 1: ASC Quality Measures, Reporting Periods, and Initial Payment Year Affected
Measure Reporting Period Payments
Affected
1. Patient Burn October 1, 2012 thru December 31, 2012 CY 2014
2. Patient Fall October 1, 2012 thru December 31, 2012 CY 2014
3. Wrong Site, Wrong Side, Wrong
Patient, Wrong Procedure,
Wrong Implant
October 1, 2012 thru December 31, 2012 CY 2014
4. Hospital Transfer/Admission October 1, 2012 thru December 31, 2012 CY 2014
5. Prophylactic Intravenous (IV)
Antibiotic Timing
October 1, 2012 thru December 31, 2012 CY 2014
6. Safe Surgery Checklist Use July 1, 2013 thru August 15, 2013 (for January
1, 2012 thru December 31, 2012)
CY 2015
7. ASC Facility Volume Data on
Selected ASC Surgical
Procedures
July 1, 2013 thru August 15, 2013 (for January
1, 2012 thru December 31, 2012)
CY 2015
8. Influenza Vaccination Coverage
Among Health Care Workers
October 1, 2014 thru March 31, 2015 CY 2016
The establishment of quality measure reporting procedures for ambulatory surgical centers was
authorized under the Medicare Improvements and Extension Act of 2006 under Title I of the Tax
Relief and Health Care Act of 2006 (Pub. L. 109-432).
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 2
Data Collection and Submission
Data for claims-based measures included in this specifications manual are to be reported for all
Medicare fee-for-service (FFS) patients admitted to the ASC during required reporting periods (see
Table 1).
For claims-based measures, the reporting period refers to dates of service, not to the claim
submission date. For example, if a service was provided on September 30, 2012 with claim
submission on October 1, 2012, this claim would not be included because the service date was
prior to the reporting period.
Data for structural measures relates to all ASC patients.
Note that specifications for the Influenza Vaccination Coverage for Health Care Workers process of
care measure are not included in this manual.
Claims-based Measures
ASCs are to submit information on the five claims-based measures using Quality Data Codes
(QDCs) entered on their claims submitted using the CMS-1500 or associated electronic dataset.
QDCs are specified CPT Category II codes or Level II G-codes that describe the clinical action
required by a measure's numerator. Clinical actions can apply to more than one condition and
therefore, can also apply to more than one measure. Some measures require more than one
clinical action and, therefore, have more than one associated QDC. Facilities should review
numerator reporting instructions carefully.
The selected QDC(s) are to be reported in addition to any codes that would be standard for billing
purposes (e.g., the ICD-9-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 for the reporting of these measures has been proposed to 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. Requirements for reporting completeness will be finalized prior to data collection
beginning in October 1, 2012.
Structural Measures
Data for structural measures are to be submitted using a web-based tool that will be located on the
QualityNet website located at www.QualityNet.org. Data collection for structural measures is
required in 2013 and the tool will be available at this time for data entry.
Public Reporting
The Secretary of Health and Human Services must establish procedures to make data collected
under the Quality Reporting Programs. Under the ASC Quality Reporting Program, facilities will be
provided the opportunity to review their data prior to publication. Details on the publication of data,
the ability to withdraw and not have data publicly reports, and reconsideration processes have
been proposed and will be finalized prior to data collection beginning October 1, 2012.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 3
THE SPECIFICATIONS MANUAL
This Specifications Manual provides measure specifications, associated QDCs with descriptions,
and references for required ASC Quality Reporting Program quality measures.
The claims-based ASC quality measures adopted by CMS for the ASC Quality Reporting Program
were developed by the ASC Quality Collaboration. These measures 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).
Information for each of the ASC Quality Collaboration measures is displayed in the following
format:
Title of Measure - Provides the title of the measure
Quality Reporting Option - States whether the measure is an outcome, structural, or a process of
care measure.
Description - A brief description of what is being measured.
Numerator - The patient population experiencing the outcome or process of care being measured.
Denominator - The patient population evaluated.
Numerator Inclusions - Patients to be included in the patient population experiencing the
outcome or process of care being measured.
Numerator Exclusions - Patients to be excluded from the patient population experiencing the
outcome or process of care being measured.
Denominator Inclusions - Patients included in the population to be evaluated.
Denominator Exclusions - Patients to be excluded from the population to be evaluated.
Coding options - A list and description of the G-code(s) used to report 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.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 4
IMPORTANT
A QDC has been established to report that the patient did not experience the events for four of
the five claims-based outcome measures. If this code is used, none of the other QDCs should
be used for these four measures.
G8907: Patient documented not to have experienced any of the following events: a burn prior
to discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong
procedure or wrong implant event; or a hospital transfer or hospital admission upon
discharge from the facility.
Note: For surgical patients with an order for prophylactic antibiotics, information on the fifth
measure, Prophylactic IV Antibiotic Timing, will be reported separately. If the patient received
the prophylactic antibiotic on time and did not experience any of the events (a burn prior to
discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong procedure or
wrong implant event; or a hospital transfer or hospital admission upon discharge from the
facility), the code listed above (G8907) would be used in addition to G8916. See each
measure for the list of available codes.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 5
Ambulatory Surgical Center (ASC) Quality Reporting Measures
Measure Title: Patient Burn
MEASURE ID #: ASC-1
REPORTING MECHANISM:
Medicare Fee-for-Service Claims
DESCRIPTION:
The number of admissions (patients) who experience a burn prior to discharge.
DENOMINATOR:
All ASC admissions
Inclusions: All ASC admissions.
Exclusions: None
NUMERATOR:
ASC admissions experiencing a burn prior to discharge.
Inclusions: ASC admissions experiencing a burn prior to discharge.
Exclusions: None
Numerator Quality-Data Coding Options for Reporting:
G8908: Patient documented to have received a burn prior to discharge.
G8909: Patient documented not to have received a burn prior to discharge.
G8907: Patient documented not to have experienced any of the following events: a burn prior to
discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong procedure
or wrong implant event; or a hospital transfer or hospital admission upon discharge from
the facility.
Note: If using code G8908 or G8909, do not use code G8907.
DEFINITIONS:
Admission - completion of registration upon entry into the facility.
Burn - Unintended tissue injury caused by any of the six recognized mechanisms: scalds, contact,
fire, chemical, electrical or radiation (e.g. warming devices, prep solutions, electrosurgical unit or
laser).
Discharge - occurs when the patient leaves the confines of the ASC.
SELECTION BASIS:
There are numerous case reports in the literature regarding patient burns in the surgical and
procedural setting. The diversity of the causative agents underscores the multitude of potential
risks that must be properly mitigated to avoid patient burns.
The literature on burns suggests that electrosurgical burns are most common. A recent publication
from the ECRI Institute (www.ecri.org) highlights the increased risk of burns with newer surgical
devices that apply higher currents at longer activation times. Although electrical burns are most
prevalent, other mechanisms of burn injury are frequently reported in case studies and case series.
These include chemical and thermal burns.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 6
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.
Recognition of the diverse mechanisms by which a patient could sustain an unintentional burn in
the ASC setting, scaling, contact, fire, chemical, electrical, or radiation, this will allow stakeholders
to develop a better understanding of the incidence of these events and further refine preventive
processes.
CLINICAL RECOMMENDATION STATEMENTS:
The risk of burns related to laser use can be reduced by adherence to the guidelines published by
the American National Standards Institute (ANSI) for safe use of these devices in the health care
setting. Similarly, the risk of burns related to the use of electrosurgical devices can be reduced by
following the electrosurgery checklist published by ECRI Institute.
The risk of surgical fires can be reduced by minimizing ignition, oxidizer, and fuel risks (the “classic
triangle”). The American Society of Anesthesiologist's Practice Advisory for the Prevention and
Management of Operating Room Fires seeks to prevent the occurrence of OR fires, reduce
adverse outcomes associated with OR fires, and identify the elements of a fire response protocol.
These guidelines are available at: http://www.asahq.org/For-Members/Practice-
Management/Practice-Parameters.aspx.
Guidance for the prevention of surgical fire has also been published by the Association of
Perioperative Registered Nurses (AORN).
REFERENCES
�� American National Standards Institutes (ANSI) Z136.3 (2005) - Safe Use of Lasers in Health
Care Facilities, 2005 Revision.
�� American Society of Anesthesiologists Task Force on Operating Room Fires, Caplan RA,
Barker SJ, et al. Practice advisory for the prevention and management of operating room
fires. Anesthesiology 2008 May;108(5):786-801.
�� ECRI Institute. New clinical guide to surgical fire prevention: patients can catch fire—here's
how to keep them safer [guidance article]. Health Devices 2009 Oct;38(10):314-32.
�� ECRI. Electrosurgery Checklist.
http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8271.
�� National Fire Protection Association (NFPA). NFPA 99: standard for health care facilities.
Quincy (MA): NFPA; 2005.
�� Association of Operating Room Nurses (AORN). AORN Guidance Statement: Fire
Prevention in the Operating Room in Standards, Recommended Practices, and Guidelines.
Denver, CO: AORN, 2006.
�� AORN. Fire safety Tool Kit. 2011.
http://www.aorn.org/PracticeResources/ToolKits/FireSafetyToolKit/.
�� National Quality Forum. Serious Reportable Events in Healthcare 2006 Update.
Washington, DC: NQF, 2007.
�� Joint Commission. Joint Commission Sentinel Event Alert. Issue 12, February 4, 2000.
Operative and Postoperative Complications: Lessons for the Future. Chicago, IL.
�� Tucker R. Laparoscopic electrosurgical injuries: survey results and their implications. Surg
Laparosc Endosc. 1995;5(4):311- 7.
�� ECRI. Higher currents, greater risks: preventing patient burns at the return-electrode site
during high-current electrosurgical procedures. Health Devices. 2005;34(8):273-9.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 7
�� Demir E, O'Dey D, and Pallua N. Accidental burns during surgery. J Burn Care Res..
2006;27(6):895-900.
�� Cheney F, Posner K, Caplan R, and Gild W. Burns from warming devices in anesthesia. A
closed claims analysis. Anesthesiology. 1994;80(4):806-10.
�� Barker S and Polson J. Fire in the operating room: a case report and laboratory study.
Anesth Anal. 2001;93:960-965.
�� ECRI. Devastation of patient fires. Health Devices. 1992;21:3-39.
�� Bhananker S, Posner K, Cheney F, Caplan R, Lee L, and Domino K. Injury and liability
associated with monitored anesthesia care: a closed claims analysis. Anesthesiology.
2006;104(2):228-34.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 8
Measure Title: Patient Fall
MEASURE ID #: ASC-2
REPORTING MECHANISMS:
Medicare Fee-for-Service Claims
DESCRIPTION:
The number of admissions (patients) who experience a fall within the ASC.
DENOMINATOR:
All ASC admissions
Inclusions: All ASC admissions.
Exclusions: None
NUMERATOR:
ASC admissions experiencing a fall within the confines of the ASC.
Inclusions: ASC admissions experiencing a fall within the confines of the ASC.
Exclusions: ASC admissions experiencing a fall outside the ASC.
Numerator Quality-Data Coding Options for Reporting:
G8910: Patient documented to have experienced a fall within the ASC.
G8911: Patient documented not to have experienced a fall within the ASC.
G8907: Patient documented not to have experienced any of the following events: a burn prior to
discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong procedure
or wrong implant event; or a hospital transfer or hospital admission upon discharge from
the facility.
Note: If using code G8910 or G8911, do not use code G8907.
DEFINITIONS:
Admission - completion of registration upon entry into the facility.
Fall - a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or
other object, excluding falls resulting from violent blows or other purposeful actions (source:
National Center for Patient Safety).
SELECTION BASIS:
“Falls per 100,000 patient days” has been endorsed as a serious reportable event by the NQF.
While ASCs have a relatively low incidence of adverse events in general; information regarding the
incidence of patient falls is not currently available. Stakeholders have expressed an interest in the
public reporting of such adverse events. Due to the use of anxiolytics, sedatives, and anesthetic
agents as adjuncts to procedures, patients undergoing outpatient surgery are at increased risk for
falls.
CLINICAL RECOMMENDATION STATEMENTS:
The Agency for Healthcare Research and Quality's (AHRQ) Prevention of Falls in Acute Care
guidelines state that patient falls can 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
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 9
for prevention; 3) performing a comprehensive evaluation of falls that occur; and 4) performing a
post-fall revision of plan of care as appropriate.
REFERENCES
�� Institute for Clinical Systems Improvement (ICSI). Prevention of falls (acute care). Health
care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2010
Apr. p 34.
�� Boushon B, Nielsen G, Quigley P, Rutherford P, Taylor J, Shannon D. Transforming Care at
the Bedside How-to Guide: Reducing Patient Injuries from Falls. Cambridge, MA: Institute
for Healthcare Improvement; 2008.
�� ECRI Institute. Falls Prevention Resources:
https://www.ecri.org/Products/Pages/Fall_Prevention_Resources.aspx.
�� Joint Commission. 2011-2012 National Patient Safety Goals:
http://www.jointcommission.org/standards_information/npsgs.aspx.
�� National Center for Patient Safety: United States Department of Veterans Affairs.
http://www.patientsafety.gov/CogAids/FallPrevention/index.html#page=page-1.
�� National Quality Forum. Serious Reportable Events in Healthcare – 2006 Update: A
Consensus Report. March 2007.
�� Gray-Micelli D. Preventing falls in acute care. In: Capezuti E, Zwicker D, Mezey M, Fulmer
T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York
(NY): Springer Publishing Company; 2008. p. 161-98.
�� American Geriatrics Society, British Geriatrics Society, American Academy of Orthopedic
Surgeons (AGS/BGS/AAOS) Guidelines for the Prevention of Falls in Older Persons (2001).
Journal of American Geriatrics Society, 49, 664–672.
�� American Medical Directors Association (AMDA). Falls and fall risk. Columbia, MD:
American Medical Directors Association.
�� ECRI Institute: Falls Prevention Strategies in Healthcare Settings (2006). Plymouth Meeting,
PA.
�� Institute for Clinical Systems Improvement. Prevention of Falls (Acute Care). Second
Edition. April 2010.
�� Resnick, B. (2003). Preventing falls in acute care. In: M. Mezey, T. Fulmer, I. Abraham
(Eds.) & D. Zwicker (Managing Ed.), Geriatric nursing protocols for best practice (2nd ed.,
pp. 141–164). New York: Springer Publishing Company, Inc.
�� University of Iowa Gerontological Nursing Interventions Research Center (UIGN). (2004).
Falls prevention for older adults. Iowa City, IA: University of Iowa Gerontological Nursing
Interventions Research Center, Research Dissemination Core.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 10
Measure Title: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong
Implant
MEASURE ID #: ASC-3
REPORTING MECHANISM:
Medicare Fee-for-Service Claims
DESCRIPTION:
Any ASC admissions (patients) who experience a wrong site, side, patient, procedure or implant.
DENOMINATOR:
All ASC admissions
Inclusions: All ASC admissions.
Exclusions: None
NUMERATOR:
All ASC admissions experiencing a wrong site, wrong side, wrong patient, wrong procedure or
wrong implant.
Inclusions: All ASC admissions experiencing a wrong site, wrong side, wrong patient,
wrong procedure or wrong implant.
Exclusions: None
Numerator Quality-Data Coding Options for Reporting:
G8912: Patient documented to have experienced a wrong site, wrong side, wrong patient, wrong
procedure or wrong implant event.
G8913: Patient documented not to have experienced a wrong site, wrong side, wrong patient,
wrong procedure or wrong implant event.
G8907: Patient documented not to have experienced any of the following events: a burn prior to
discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong procedure
or wrong implant event; or a hospital transfer or hospital admission upon discharge from
the facility.
Note: If using code G8912 or G8913, do not use code G8907.
DEFINITIONS:
Admission - completion of registration upon entry into the facility.
Wrong - not in accordance with intended site, side, patient, procedure or implant.
SELECTION BASIS:
“Surgery performed on the wrong body part,” “surgery performed on the wrong patient,” and “wrong
surgical procedure performed on a patient” have all been endorsed as serious reportable surgical
events by NQF. This outcome measure serves as an indirect measure of providers' adherence to
The Joint Commission, 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 forty professional medical associations
and organizations. To encompass the outcomes of all key identification verifications, the ASC
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 11
Quality Collaboration's measure incorporates not only wrong site, wrong side, wrong patient and
wrong procedure, but also wrong implant in its specifications.
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.
REFERENCES
�� 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.
�� American Academy of Ophthalmology. Recommendations of American Academy of
Ophthalmology Wrong-Site Task Force.
http://one.aao.org/ce/practiceguidelines/patient_content.aspx?cid=d0db838c-2847-4535-
baca-aebab3011217.
�� American Academy of Orthopaedic Surgeons. Wrong-Site Surgery. Information Statement
1015 http://www.aaos.org/about/papers/advistmt/1015.asp.
�� American College of Obstetricians and Gynecologists. ACOG committee opinion #464:
patient safety in the surgical environment. Obstet Gynecol. 2010; 116(3):786-790.
�� American College of Surgeons. [ST-41] Statement on ensuring correct patient, correct site,
and correct procedure surgery http://www.facs.org/fellows_info/statements/st-41.html
�� AORN. AORN Position Statement on Preventing Wrong-Patient, Wrong-Site, Wrong-
Procedure Events.
http://www.aorn.org/PracticeResources/AORNPositionStatements/PositionCorrectSiteSurge
ry/.
�� Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC:
National Academy Press, 2000.
�� Joint Commission. 2011 National Patient Safety Goals.
http://www.jointcommission.org/standards_information/npsgs.aspx.
�� National Quality Forum. Serious Reportable Events in Healthcare – 2006 Update: A
Consensus Report. March 2007.
�� World Health Organization. WHO Guidelines for Safe Surgery 2009.
http://whqlibdoc.who.int/publications/2009/9789241598552_eng.pdf.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 12
Measure Title: Hospital Transfer/Admission
MEASURE ID #: ASC-4
REPORTING MECHANISM:
Medicare-Fee-for-Service Claims
DESCRIPTION:
ASC admissions (patients) who are transferred or admitted to a hospital upon discharge from the
ASC.
DENOMINATOR:
All ASC admissions
Inclusions: All ASC admissions.
Exclusions: None
NUMERATOR:
ASC admissions requiring a hospital transfer or hospital admission upon discharge from the ASC.
Inclusions: ASC admissions requiring a hospital transfer or hospital admission upon
discharge from the ASC.
Exclusions: None
Numerator Quality-Data Coding Options for Reporting:
G8914: Patient documented to have experienced a hospital transfer or hospital admission upon
discharge from ASC.
G8915: Patient documented not to have experienced a hospital transfer or hospital admission
upon discharge from ASC.
G8907: Patient documented not to have experienced any of the following events: a burn prior to
discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong procedure
or wrong implant event; or a hospital transfer or hospital admission upon discharge from
the facility.
Note: If using code G8914 or G8915, do not use code G8907.
DEFINITIONS:
Admission - completion of registration upon entry into the facility.
Hospital Transfer/Admission - any transfer/admission from an ASC directly to an acute care
hospital including hospital emergency room.
Discharge - occurs when the patient leaves the confines of the ASC.
SELECTION BASIS:
The need for transfer/admission is an unanticipated outcome and could be the result of insufficient
rigor in patient or procedure selection. Hospital transfers/admissions can result in unplanned cost
and time burdens that must be borne by patients and payers.
Selected states have expressed an interest in the public reporting of such events. While hospital
transfers and admissions undoubtedly represent good patient care when necessary, high rates
may be an indicator that practice patterns or patient selection guidelines are in need of review.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 13
CLINICAL RECOMMENDATION STATEMENTS:
No clinical practice guidelines specifically addressing transfers or admissions from ASCs to acute
care hospitals are available at this time.
REFERENCES
�� Coley K et al. Retrospective evaluation of unanticipated admissions and readmissions after
same day surgery and associated costs. J Clin Anesth. 2002;14:349-353.
�� Lin D, Dalgorf D, Witterick IJ. Predictors of unexpected hospital admissions after outpatient
endoscopic sinus surgery: retrospective review. J Otolaryngol Head Neck Surg. 2008
Jun;37(3):309-11.
�� Hofer RE, Kai T, Decker PA, Warner DO. Obesity as a risk factor for unanticipated
admissions after ambulatory surgery. Mayo Clin Proc. 2008 Aug;83(8):908-16.
�� Tewfik MA, Frenkiel S, Gasparrini R, Zeitouni A, Daniel SJ, Dolev Y, Kost K, Samaha M,
Sweet R, Tewfik TL. Factors affecting unanticipated hospital admission following
otolaryngologic day surgery. J Otolaryngol. 2006 Aug;35(4):235-41.
�� Shirakami G, Teratani Y, Namba T, Hirakata H, Tazuke-Nishimura M, ***uda K. Delayed
discharge and acceptability of ambulatory surgery in adult outpatients receiving general
anesthesia. J Anesth. 2005;19(2):93-101.
�� Lau H, Brooks DC. Predictive factors for unanticipated admissions after ambulatory
laparoscopic cholecystectomy. Arch Surg. 2001 Oct;136(10):1150-3.
�� Junger A, Klasen J, Benson M, Sciuk G, Hartmann B, Sticher J, Hempelmann G. Factors
determining length of stay of surgical day-case patients. Eur J Anaesthesiol. 2001
May;18(5):314-21.
�� Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery—a prospective
study. Can J Anaesth. 1998 Jul;45(7):612-9.
�� Margovsky A. Unplanned admissions in day-case surgery as a clinical indicator for quality
assurance. Aust N Z J Surg. 2000 Mar;70(3):216-20.
�� Lledó JB, Planells M, Espí A, Serralta A, García R, Sanahuja A. Predictive model of failure
of outpatient laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech. 2008
Jun;18(3):248-53.
�� Shaikh S, Chung F, Imarengiaye C, Yung D, Bernstein M. Pain, nausea, vomiting and
ocular complications delay discharge following ambulatory microdiscectomy. Can J
Anaesth. 2003 May;50(5):514-8.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 14
Measure Title: Prophylactic Intravenous (IV) Antibiotic Timing
MEASURE ID #: ASC-5
REPORTING MECHANISM:
Medicare-Fee-for-Service Claims
DESCRIPTION:
Intravenous (IV) antibiotics given for prevention of surgical site infection were administered on
time.
DENOMINATOR:
All ASC admissions with a preoperative order for a prophylactic IV antibiotic for prevention of
surgical site infection.
Inclusions: All ASC admissions with a preoperative order for a prophylactic IV antibiotic for
prevention of surgical site infection.
Exclusions: ASC admissions with a preoperative order for a prophylactic IV antibiotic for
prevention of infections other than surgical site infections (e.g. bacterial endocarditis); ASC
admissions with a preoperative order for a prophylactic antibiotic not administered by the
intravenous route.
NUMERATOR:
Number of ASC admissions with an order for a prophylactic IV antibiotic for prevention of surgical
site infection who received the prophylactic antibiotic on time.
Inclusions: All ASC admissions with a preoperative order for a prophylactic IV antibiotic for
prevention of surgical site infection.
Exclusions: None
Numerator Quality-Data Coding Options for Reporting:
G8916: Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis,
antibiotic initiated on time.
G8917: Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis,
antibiotic not initiated on time.
G8918: Patient without preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis.
Note: The QDC of G8907 can be used If the patient did not experience any of the events for the
four outcome measures (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); this code would be used plus one of the codes above
for the prophylactic antibiotic timing measure for complete reporting of the 5 claims-based
measures.
DEFINITIONS:
Admission - completion of registration upon entry into the facility.
Antibiotic administered on time - Antibiotic infusion is initiated within one hour prior to the time of
the initial surgical incision or the beginning of the procedure (e.g., introduction of endoscope,
insertion of needle, inflation of tourniquet) or two hours prior if vancomycin or fluoroquinolones are
administered.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 15
Intravenous - Administration of a drug within a vein, including bolus, infusion or IV piggyback.
Order - a written order, verbal order, standing order or standing protocol.
Prophylactic antibiotic - an antibiotic prescribed with the intent of reducing the probability of an
infection related to an invasive procedure. For purposes of this measure, the following antibiotics
are considered prophylaxis for surgical site infections: Ampicillin/sulbactam, Aztreonam, Cefazolin,
Cefmetazole, Cefotetan, Cefoxitin, Cefuroxime, Ciprofloxacin, Clindamycin, Ertapenem,
Erythromycin, Gatifloxacin, Gentamicin, Levofloxacin, Metronidazole, Moxifloxacin, Neomycin and
Vancomycin.
SELECTION BASIS:
The CMS Surgical Infection Prevention performance measure states, “Surgical site infections occur
in 2-5 percent of clean extra-abdominal surgeries and up to 20 percent of intra-abdominal
surgeries. Each infection is estimated to increase a hospital stay by an average of 7 days and add
over $3,000 in charges (1992 data). Patients who develop surgical site infections are 60 percent
more likely to spend time in an ICU (intensive care unit), five times more likely to be readmitted to
the hospital, and have twice the incidence of mortality. Despite advances in infection control
practices, surgical site infections remain a substantial cause of morbidity and mortality among
hospitalized patients. Studies indicate that appropriate preoperative administration of antibiotics is
effective in preventing infection. Systemic and process changes that promote compliance with
established guidelines and standards can decrease infectious morbidity.”
There is no literature available on variation in adherence to recommended prophylactic IV antibiotic
timing among ASC providers. However, variability in the accuracy of timing of administration has
been demonstrated in other clinical settings.
CLINICAL RECOMMENDATION STATEMENTS:
This performance measure is aligned with current surgical infection prevention guidelines
recommending that prophylactic antibiotics be administered within one hour prior to surgical
incision, or within two hours prior to incision when vancomycin or fluoroquinolones are used.
REFERENCES
�� Horan T, Culver D, Gaynes R, Jarvis W, Edwards J, and Reid C. Nosocomial infections in
surgical patients in the United States, January 1986-June 1992. National Nosocomial
Infections Surveillance (NNIS) System. Infect Control HospEpidemiol. 1993; 14(2):73-80.
�� Marton W, Jarvis W, Culver D, and Haley R. Incidence and nature of endemic and epidemic
nosocomial infections. In: Bennett J, Brachman P, editor(s). Hospital infections. 3rd ed.
Boston, MA: Little, Brown and Co.; 1992. 577-596.
�� Kirkland K, Briggs J, Trivette S, Wilkinson W, and Sexton D. The impact of surgical-site
infections in the 1990s: attributable mortality, excess length of hospitalization, and extra
costs. Infect Control Hosp Epidemiol. 1999; 20(11):725-30.
�� Burke J. Maximizing appropriate antibiotic prophylaxis for surgical patients: an update from
LDS Hospital, Salt Lake City. Clin Infect Dis. 2001; 33(Suppl 2):S78-83.
�� Classen D et al. The timing of prophylactic administration of antibiotics and the risk of
surgical wound infection. NEJM. 1992; 326(5):281-286.
�� Silver A et al. Timeliness and use of antibiotic prophylaxis in selected inpatient surgical
procedures. The Antibiotic Prophylaxis Study Group. Am J Surg. 1996; 171(6):548-552.
�� Papaioannou N, Kalivas L, Kalavritinos J, and Tsourvakas S. Tissue concentrations of thirdgeneration
cephalosporins (ceftazidime and ceftriaxone) in lower extremity tissues using a
tourniquet. Arch Orthop Trauma Surg. 1994; 113(3):167-9.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 16
�� Dounis E, Tsourvakas S, Kalivas L, and Giamacellou H. Effect of time interval on tissue
concentrations of cephalosporins after tourniquet inflation. Highest levels achieved by
administration 20 minutes before inflation. Acta Orthop Scand. 1995; 66(2):158-60.
�� Friedrich L, White R, Brundage D, Kays M, Friedman R. The effect of tourniquet inflation on
cefazolin tissue penetration during total knee arthroplasty. Pharmacotherapy. 1990;
10(6):373-7.
�� Steinberg JP, Barun BI, Hellinger WC, Kusek L, Bozikis MR, Bush AJ, Dellinger EP, Burke
JP, Simmons B, Kritchevsky SB, Trial to reduce antimicrobial prophylaxis errors (TRAPE)
study group. Timing of antimicrobial prophylaxis and the risk of surgical site infections:
results from the trial to reduce antimicrobial prophylaxis errors. Ann Surg 2009; 250(1):10-6.
�� Forbes SS, Stephen WJ, Harper WL, Loeb M, Smith R, Christoffersen EP, McLean RF.
Implementation of evidence-based practices for surgical site infection prophylaxis: results of
a pre- and post intervention study. J Am Coll Surg. 2008 Sep; 207(3):336-41.
�� Koopman E, Nix DE, Erstad BL, Demeure MJ, Hayes MM, Ruth JT, Mattias KR. End-ofprocedure
cefazolin concentrations after administration for prevention of surgical-site
infection. Am J Health Syst Pharm. 2007 Sep; 64(18):1927-34.
�� Manniën J, van Kasteren ME, Nagelkerke NJ, Gyssens IC, Kullberg BJ, Wille JC, de Boer
AS. Effect of optimized antibiotic prophylaxis on the incidence of surgical site infection.
Infect Control Hosp Epidemiol. 2006; 27(12):1340-6.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 17
Measure Title: ASC Facility Volume Data on Selected ASC Surgical Procedures
MEASURE ID#: ASC-6
REPORTING MECHANISM:
Web-based tool on QualityNet
DESCRIPTION: The aggregate count of selected surgical procedures. Most ASC procedures fall
into one of eight categories: Cardiovascular, Eye, Gastrointestinal, Genitourinary, Musculoskeletal,
Nervous System, Respiratory, and Skin. The eight categories and corresponding HCPCS are
listed in the table below. The procedures and codes in Table 2 were selected based on recent ASC
data and update the procedure codes listed in the Calendar Year (CY) 2012 OPPS/ASC Final Rule
with Comment Period (CMS-1525-FC).
Measure ascertains response to the following question(s):
�� What was the aggregate count of selected surgical procedures per category?
Annual data submission period: July 1, 2013 – August 15, 2013 covering the performance
period January 1, 2012- December 31, 2012.
Table 2: Categories and HCPCS for ASC-6
Organ System CMS Procedure Category Surgical Procedure Codes
Cardiovascular Placement of long-term vascular
access catheter
36561
Vascular procedures to improve
blood flow to coronary (heart)
vessels
92980, 92981, 92982, 92984
Eye Organ transplant (eye) 65756, V2785
Laser procedure of eye 65855, 66761, 66821
Glaucoma procedures 66170, 66180
Cataract procedures 66982, 66984
Injection of eye 67028, J2778, J3300, J3396
Retina, macular and posterior
segment procedures
67041, 67042, 67210, 67228
Repair of surrounding eye structures 67900, 67904, 67917, 67924
Gastrointestinal GI endoscopy procedures 43239, 43235, 43248, 43249, 43251,
44361, 45330, 45331, 45378, 45380,
45381, 45383, 45384, 45385
Swallowing tube (esophagus) 43450
Hernia repair 49505
GI screening procedures G0105, G0121
Genitourinary Kidney stone fragmentation 50590
Bladder related procedures 52000, 52005, 52204, 52281, 52310,
52332,
Prostate biopsy 55700
Radiologic procedures (GU) 74420
Ultrasound procedures (GU) 76872
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 18
Musculoskeletal Joint or muscle aspiration or injection 20610
Removal of musculoskeletal implants 20680
Repair of tendons and ligaments 23412
Repair of foot, toes, fingers, and wrist 26055, 28270, 28285, 28296, , 29848
Removal of musculoskeletal lesion 26160
Joint arthroscopy 29824, 29826, 29827, 29880, 29881
Musculoskeletal drug injection J0585
Nervous Injection procedures in or around the
spine
62310, 62311, 64479, 64483, 64484,
64490, 64491, 64492, 64493, 64494,
64495, 64622, 64623, 64626, 64627,
G0260
Device implant 63650
Nerve decompression 64718
Repair of foot, toes, fingers, and wrist 64721
Respiratory Sinus procedure 31255
Skin Skin procedures 11042, 13132, 14040, 14060, 15260,
Q4101, Q4102, Q4106
Repair of surrounding eye structures 15823
Multi-system* Brachytherapy C2638, C2639, C2640, C2641
Cancer treatment C9257
*Multi-System: procedures that can be performed in more than one organ system.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 19
Measure Title: Safe Surgery Checklist Use
MEASURE ID #: ASC-7
REPORTING MECHANISM:
Web-based tool on QualityNet
Description: The use of a Safe Surgery Checklist for surgical procedures that includes safe
surgery practices during each of the three critical perioperative periods: the period prior to the
administration of anesthesia, the period prior to skin incision, and the period of closure of incision
and prior to the patient leaving the operating room.
Measure ascertains response to the following question(s):
�� Does/did your facility use a safe surgery checklist based on accepted standards of practice
at any time during the designated period? Yes/No
Annual data submission period: July 1, 2013 – August 15, 2013 covering the designated time
period January 1, 2012- December 31, 2012.
Examples for Safe Surgery Practices*
First critical point (period
prior to administering
anesthesia)
Second critical point (period
prior to skin incision)
Third critical point (period of
closure of incision and prior
to patient leaving the
operating room)
�� Verbal confirmation of
patient identity
�� Mark surgical site
�� Check anesthesia
machine/medication
�� Assessment of allergies,
airway and aspiration
risk
�� Confirm surgical team
members and roles
�� Confirm patient identity,
procedure and surgical
incision site
�� Administration of
antibiotic prophylaxis
within 60 minutes before
incision
�� Communication among
surgical team members
of anticipated critical
events
�� Display of essential
imaging as appropriate
�� Confirm the procedure
�� Complete count of
surgical instruments and
accessories
�� Identify key patient
concerns for recovery
and management of the
patient
*Hospital safe surgery checklist items are not limited to the examples listed in this table.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 20
APPENDIX A: DATA DEFINITIONS
Admission: Completion of registration upon entry into the facility.
Antibiotic administered on time: Antibiotic infusion is initiated within one hour prior to the time of
the initial surgical incision or the beginning of the procedure (e.g., introduction of endoscope,
insertion of needle, inflation of tourniquet) or two hours prior if vancomycin or fluoroquinolones are
administered.
Burn: Unintended tissue injury caused by any of the six recognized mechanisms: scalds, contact,
fire, chemical, electrical or radiation, (e.g. warming devices, prep solutions, electrosurgical unit or
laser).
Discharge: Occurs when the patient leaves the confines of the ASC.
Fall: A sudden, uncontrolled, unintentional, downward displacement of the body to the ground or
other object, excluding falls resulting from violent blows or other purposeful actions. (National
Center for Patient Safety)
Hospital transfer/admission: Any transfer/admission from an ASC directly to an acute care
hospital including hospital emergency room or emergency department.
Intravenous: Administration of a drug within a vein, including bolus, infusion or IV piggyback.
Order: A written order, verbal order, standing order or standing protocol.
Prophylactic antibiotic: An antibiotic prescribed with the intent of reducing the probability of an
infection related to an invasive procedure. For purposes of the Prophylactic IV Antibiotic Timing
measure, the following antibiotics are considered prophylaxis for surgical site infections:
Ampicillin/sulbactam, Aztreonam, Cefazolin, Cefmetazole, Cefotetan, Cefoxitin, Cefuroxime,
Ciprofloxacin, Clindamycin, Ertapenem, Erythromycin, Gatifloxacin, Gentamicin, Levofloxacin,
Metronidazole, Moxifloxacin, Neomycin and Vancomycin.
Quality Data Code (QDC): Non-payable Healthcare Common Procedure Coding System
(HCPCS) codes comprised of specified CPT Category II codes and/or G-codes that describe the
clinical action required by a measure's numerator.
Wrong: Not in accordance with intended site, side, patient, procedure or implant.
Additional information and resources, such as sample data collection sheets or logs and frequently
asked questions (FAQs) about the measures, can be found on the ASC Quality Collaboration
website at www.ascquality.org.
Centers for Medicare & Medicaid Services
Ambulatory Surgical Center
Quality Reporting Program
Quality Measures
Specifications Manual
Version 1.0
April 2012
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program i
TABLE OF CONTENTS
BACKGROUND .................................................................................................................... 1
THE SPECIFICATIONS MANUAL ....................................................................................... 3
Ambulatory Surgical Center (ASC) Quality Reporting Measures ........................................... 5
Patient Burn ............................................................................................................................... 5
Patient Fall ................................................................................................................................ 8
Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant .......................... 10
Hospital Transfer/Admission .................................................................................................... 12
Prophylactic Intravenous (IV) Antibiotic Timing ........................................................................ 14
ASC Facility Volume Data on Selected ASC Surgical Procedures .......................................... 17
Safe Surgery Checklist Use ..................................................................................................... 19
APPENDIX A: DATA DEFINITIONS ................................................................................. 20
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 1
BACKGROUND
Quality Reporting for Ambulatory Surgical Centers
Welcome to quality reporting for Ambulatory Surgical Centers (ASCs)! This manual provides
specifications for quality measures finalized for reporting to meet requirements for this recently
finalized program.
A quality reporting program for ASCs was finalized by the Centers for Medicare and Medicaid
Services (CMS) in the Calendar Year (CY) 2012 OPPS/ASC Final Rule with Comment Period
(CMS-1525-FC). Five claims-based measures (four outcome measures and one process of care
measure) were adopted for the CY 2014 payment determination. For the CY 2015 payment
determination, the same claims-based measures and two structural measures (surgical procedure
volume and safe surgery checklist use) were adopted for a total of seven quality measures. For the
CY 2016 payment determination, the same claims-based and structural measures as adopted for
the CY 2015 payment determination and one process of care measure were adopted.
ASCs that do not meet program requirements for ASC Quality Reporting may receive a 2 percent
reduction in their ASC annual payment update. Thus, only separately identifiable entities certified
as ASC by Medicare are affected by program requirements and possible payment penalty under
the ASC Quality Reporting Program. The definition of an ASC can be found in the Claims
Processing Manual, Chapter 14, Section 10.1 located on the CMS website (www.cms.hhs.gov).
The below table summarizes the quality measures, reporting periods, and payment years affected.
Table 1: ASC Quality Measures, Reporting Periods, and Initial Payment Year Affected
Measure Reporting Period Payments
Affected
1. Patient Burn October 1, 2012 thru December 31, 2012 CY 2014
2. Patient Fall October 1, 2012 thru December 31, 2012 CY 2014
3. Wrong Site, Wrong Side, Wrong
Patient, Wrong Procedure,
Wrong Implant
October 1, 2012 thru December 31, 2012 CY 2014
4. Hospital Transfer/Admission October 1, 2012 thru December 31, 2012 CY 2014
5. Prophylactic Intravenous (IV)
Antibiotic Timing
October 1, 2012 thru December 31, 2012 CY 2014
6. Safe Surgery Checklist Use July 1, 2013 thru August 15, 2013 (for January
1, 2012 thru December 31, 2012)
CY 2015
7. ASC Facility Volume Data on
Selected ASC Surgical
Procedures
July 1, 2013 thru August 15, 2013 (for January
1, 2012 thru December 31, 2012)
CY 2015
8. Influenza Vaccination Coverage
Among Health Care Workers
October 1, 2014 thru March 31, 2015 CY 2016
The establishment of quality measure reporting procedures for ambulatory surgical centers was
authorized under the Medicare Improvements and Extension Act of 2006 under Title I of the Tax
Relief and Health Care Act of 2006 (Pub. L. 109-432).
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 2
Data Collection and Submission
Data for claims-based measures included in this specifications manual are to be reported for all
Medicare fee-for-service (FFS) patients admitted to the ASC during required reporting periods (see
Table 1).
For claims-based measures, the reporting period refers to dates of service, not to the claim
submission date. For example, if a service was provided on September 30, 2012 with claim
submission on October 1, 2012, this claim would not be included because the service date was
prior to the reporting period.
Data for structural measures relates to all ASC patients.
Note that specifications for the Influenza Vaccination Coverage for Health Care Workers process of
care measure are not included in this manual.
Claims-based Measures
ASCs are to submit information on the five claims-based measures using Quality Data Codes
(QDCs) entered on their claims submitted using the CMS-1500 or associated electronic dataset.
QDCs are specified CPT Category II codes or Level II G-codes that describe the clinical action
required by a measure's numerator. Clinical actions can apply to more than one condition and
therefore, can also apply to more than one measure. Some measures require more than one
clinical action and, therefore, have more than one associated QDC. Facilities should review
numerator reporting instructions carefully.
The selected QDC(s) are to be reported in addition to any codes that would be standard for billing
purposes (e.g., the ICD-9-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 for the reporting of these measures has been proposed to 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. Requirements for reporting completeness will be finalized prior to data collection
beginning in October 1, 2012.
Structural Measures
Data for structural measures are to be submitted using a web-based tool that will be located on the
QualityNet website located at www.QualityNet.org. Data collection for structural measures is
required in 2013 and the tool will be available at this time for data entry.
Public Reporting
The Secretary of Health and Human Services must establish procedures to make data collected
under the Quality Reporting Programs. Under the ASC Quality Reporting Program, facilities will be
provided the opportunity to review their data prior to publication. Details on the publication of data,
the ability to withdraw and not have data publicly reports, and reconsideration processes have
been proposed and will be finalized prior to data collection beginning October 1, 2012.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 3
THE SPECIFICATIONS MANUAL
This Specifications Manual provides measure specifications, associated QDCs with descriptions,
and references for required ASC Quality Reporting Program quality measures.
The claims-based ASC quality measures adopted by CMS for the ASC Quality Reporting Program
were developed by the ASC Quality Collaboration. These measures 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).
Information for each of the ASC Quality Collaboration measures is displayed in the following
format:
Title of Measure - Provides the title of the measure
Quality Reporting Option - States whether the measure is an outcome, structural, or a process of
care measure.
Description - A brief description of what is being measured.
Numerator - The patient population experiencing the outcome or process of care being measured.
Denominator - The patient population evaluated.
Numerator Inclusions - Patients to be included in the patient population experiencing the
outcome or process of care being measured.
Numerator Exclusions - Patients to be excluded from the patient population experiencing the
outcome or process of care being measured.
Denominator Inclusions - Patients included in the population to be evaluated.
Denominator Exclusions - Patients to be excluded from the population to be evaluated.
Coding options - A list and description of the G-code(s) used to report 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.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 4
IMPORTANT
A QDC has been established to report that the patient did not experience the events for four of
the five claims-based outcome measures. If this code is used, none of the other QDCs should
be used for these four measures.
G8907: Patient documented not to have experienced any of the following events: a burn prior
to discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong
procedure or wrong implant event; or a hospital transfer or hospital admission upon
discharge from the facility.
Note: For surgical patients with an order for prophylactic antibiotics, information on the fifth
measure, Prophylactic IV Antibiotic Timing, will be reported separately. If the patient received
the prophylactic antibiotic on time and did not experience any of the events (a burn prior to
discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong procedure or
wrong implant event; or a hospital transfer or hospital admission upon discharge from the
facility), the code listed above (G8907) would be used in addition to G8916. See each
measure for the list of available codes.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 5
Ambulatory Surgical Center (ASC) Quality Reporting Measures
Measure Title: Patient Burn
MEASURE ID #: ASC-1
REPORTING MECHANISM:
Medicare Fee-for-Service Claims
DESCRIPTION:
The number of admissions (patients) who experience a burn prior to discharge.
DENOMINATOR:
All ASC admissions
Inclusions: All ASC admissions.
Exclusions: None
NUMERATOR:
ASC admissions experiencing a burn prior to discharge.
Inclusions: ASC admissions experiencing a burn prior to discharge.
Exclusions: None
Numerator Quality-Data Coding Options for Reporting:
G8908: Patient documented to have received a burn prior to discharge.
G8909: Patient documented not to have received a burn prior to discharge.
G8907: Patient documented not to have experienced any of the following events: a burn prior to
discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong procedure
or wrong implant event; or a hospital transfer or hospital admission upon discharge from
the facility.
Note: If using code G8908 or G8909, do not use code G8907.
DEFINITIONS:
Admission - completion of registration upon entry into the facility.
Burn - Unintended tissue injury caused by any of the six recognized mechanisms: scalds, contact,
fire, chemical, electrical or radiation (e.g. warming devices, prep solutions, electrosurgical unit or
laser).
Discharge - occurs when the patient leaves the confines of the ASC.
SELECTION BASIS:
There are numerous case reports in the literature regarding patient burns in the surgical and
procedural setting. The diversity of the causative agents underscores the multitude of potential
risks that must be properly mitigated to avoid patient burns.
The literature on burns suggests that electrosurgical burns are most common. A recent publication
from the ECRI Institute (www.ecri.org) highlights the increased risk of burns with newer surgical
devices that apply higher currents at longer activation times. Although electrical burns are most
prevalent, other mechanisms of burn injury are frequently reported in case studies and case series.
These include chemical and thermal burns.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 6
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.
Recognition of the diverse mechanisms by which a patient could sustain an unintentional burn in
the ASC setting, scaling, contact, fire, chemical, electrical, or radiation, this will allow stakeholders
to develop a better understanding of the incidence of these events and further refine preventive
processes.
CLINICAL RECOMMENDATION STATEMENTS:
The risk of burns related to laser use can be reduced by adherence to the guidelines published by
the American National Standards Institute (ANSI) for safe use of these devices in the health care
setting. Similarly, the risk of burns related to the use of electrosurgical devices can be reduced by
following the electrosurgery checklist published by ECRI Institute.
The risk of surgical fires can be reduced by minimizing ignition, oxidizer, and fuel risks (the “classic
triangle”). The American Society of Anesthesiologist's Practice Advisory for the Prevention and
Management of Operating Room Fires seeks to prevent the occurrence of OR fires, reduce
adverse outcomes associated with OR fires, and identify the elements of a fire response protocol.
These guidelines are available at: http://www.asahq.org/For-Members/Practice-
Management/Practice-Parameters.aspx.
Guidance for the prevention of surgical fire has also been published by the Association of
Perioperative Registered Nurses (AORN).
REFERENCES
�� American National Standards Institutes (ANSI) Z136.3 (2005) - Safe Use of Lasers in Health
Care Facilities, 2005 Revision.
�� American Society of Anesthesiologists Task Force on Operating Room Fires, Caplan RA,
Barker SJ, et al. Practice advisory for the prevention and management of operating room
fires. Anesthesiology 2008 May;108(5):786-801.
�� ECRI Institute. New clinical guide to surgical fire prevention: patients can catch fire—here's
how to keep them safer [guidance article]. Health Devices 2009 Oct;38(10):314-32.
�� ECRI. Electrosurgery Checklist.
http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8271.
�� National Fire Protection Association (NFPA). NFPA 99: standard for health care facilities.
Quincy (MA): NFPA; 2005.
�� Association of Operating Room Nurses (AORN). AORN Guidance Statement: Fire
Prevention in the Operating Room in Standards, Recommended Practices, and Guidelines.
Denver, CO: AORN, 2006.
�� AORN. Fire safety Tool Kit. 2011.
http://www.aorn.org/PracticeResources/ToolKits/FireSafetyToolKit/.
�� National Quality Forum. Serious Reportable Events in Healthcare 2006 Update.
Washington, DC: NQF, 2007.
�� Joint Commission. Joint Commission Sentinel Event Alert. Issue 12, February 4, 2000.
Operative and Postoperative Complications: Lessons for the Future. Chicago, IL.
�� Tucker R. Laparoscopic electrosurgical injuries: survey results and their implications. Surg
Laparosc Endosc. 1995;5(4):311- 7.
�� ECRI. Higher currents, greater risks: preventing patient burns at the return-electrode site
during high-current electrosurgical procedures. Health Devices. 2005;34(8):273-9.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 7
�� Demir E, O'Dey D, and Pallua N. Accidental burns during surgery. J Burn Care Res..
2006;27(6):895-900.
�� Cheney F, Posner K, Caplan R, and Gild W. Burns from warming devices in anesthesia. A
closed claims analysis. Anesthesiology. 1994;80(4):806-10.
�� Barker S and Polson J. Fire in the operating room: a case report and laboratory study.
Anesth Anal. 2001;93:960-965.
�� ECRI. Devastation of patient fires. Health Devices. 1992;21:3-39.
�� Bhananker S, Posner K, Cheney F, Caplan R, Lee L, and Domino K. Injury and liability
associated with monitored anesthesia care: a closed claims analysis. Anesthesiology.
2006;104(2):228-34.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 8
Measure Title: Patient Fall
MEASURE ID #: ASC-2
REPORTING MECHANISMS:
Medicare Fee-for-Service Claims
DESCRIPTION:
The number of admissions (patients) who experience a fall within the ASC.
DENOMINATOR:
All ASC admissions
Inclusions: All ASC admissions.
Exclusions: None
NUMERATOR:
ASC admissions experiencing a fall within the confines of the ASC.
Inclusions: ASC admissions experiencing a fall within the confines of the ASC.
Exclusions: ASC admissions experiencing a fall outside the ASC.
Numerator Quality-Data Coding Options for Reporting:
G8910: Patient documented to have experienced a fall within the ASC.
G8911: Patient documented not to have experienced a fall within the ASC.
G8907: Patient documented not to have experienced any of the following events: a burn prior to
discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong procedure
or wrong implant event; or a hospital transfer or hospital admission upon discharge from
the facility.
Note: If using code G8910 or G8911, do not use code G8907.
DEFINITIONS:
Admission - completion of registration upon entry into the facility.
Fall - a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or
other object, excluding falls resulting from violent blows or other purposeful actions (source:
National Center for Patient Safety).
SELECTION BASIS:
“Falls per 100,000 patient days” has been endorsed as a serious reportable event by the NQF.
While ASCs have a relatively low incidence of adverse events in general; information regarding the
incidence of patient falls is not currently available. Stakeholders have expressed an interest in the
public reporting of such adverse events. Due to the use of anxiolytics, sedatives, and anesthetic
agents as adjuncts to procedures, patients undergoing outpatient surgery are at increased risk for
falls.
CLINICAL RECOMMENDATION STATEMENTS:
The Agency for Healthcare Research and Quality's (AHRQ) Prevention of Falls in Acute Care
guidelines state that patient falls can 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
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 9
for prevention; 3) performing a comprehensive evaluation of falls that occur; and 4) performing a
post-fall revision of plan of care as appropriate.
REFERENCES
�� Institute for Clinical Systems Improvement (ICSI). Prevention of falls (acute care). Health
care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2010
Apr. p 34.
�� Boushon B, Nielsen G, Quigley P, Rutherford P, Taylor J, Shannon D. Transforming Care at
the Bedside How-to Guide: Reducing Patient Injuries from Falls. Cambridge, MA: Institute
for Healthcare Improvement; 2008.
�� ECRI Institute. Falls Prevention Resources:
https://www.ecri.org/Products/Pages/Fall_Prevention_Resources.aspx.
�� Joint Commission. 2011-2012 National Patient Safety Goals:
http://www.jointcommission.org/standards_information/npsgs.aspx.
�� National Center for Patient Safety: United States Department of Veterans Affairs.
http://www.patientsafety.gov/CogAids/FallPrevention/index.html#page=page-1.
�� National Quality Forum. Serious Reportable Events in Healthcare – 2006 Update: A
Consensus Report. March 2007.
�� Gray-Micelli D. Preventing falls in acute care. In: Capezuti E, Zwicker D, Mezey M, Fulmer
T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York
(NY): Springer Publishing Company; 2008. p. 161-98.
�� American Geriatrics Society, British Geriatrics Society, American Academy of Orthopedic
Surgeons (AGS/BGS/AAOS) Guidelines for the Prevention of Falls in Older Persons (2001).
Journal of American Geriatrics Society, 49, 664–672.
�� American Medical Directors Association (AMDA). Falls and fall risk. Columbia, MD:
American Medical Directors Association.
�� ECRI Institute: Falls Prevention Strategies in Healthcare Settings (2006). Plymouth Meeting,
PA.
�� Institute for Clinical Systems Improvement. Prevention of Falls (Acute Care). Second
Edition. April 2010.
�� Resnick, B. (2003). Preventing falls in acute care. In: M. Mezey, T. Fulmer, I. Abraham
(Eds.) & D. Zwicker (Managing Ed.), Geriatric nursing protocols for best practice (2nd ed.,
pp. 141–164). New York: Springer Publishing Company, Inc.
�� University of Iowa Gerontological Nursing Interventions Research Center (UIGN). (2004).
Falls prevention for older adults. Iowa City, IA: University of Iowa Gerontological Nursing
Interventions Research Center, Research Dissemination Core.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 10
Measure Title: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong
Implant
MEASURE ID #: ASC-3
REPORTING MECHANISM:
Medicare Fee-for-Service Claims
DESCRIPTION:
Any ASC admissions (patients) who experience a wrong site, side, patient, procedure or implant.
DENOMINATOR:
All ASC admissions
Inclusions: All ASC admissions.
Exclusions: None
NUMERATOR:
All ASC admissions experiencing a wrong site, wrong side, wrong patient, wrong procedure or
wrong implant.
Inclusions: All ASC admissions experiencing a wrong site, wrong side, wrong patient,
wrong procedure or wrong implant.
Exclusions: None
Numerator Quality-Data Coding Options for Reporting:
G8912: Patient documented to have experienced a wrong site, wrong side, wrong patient, wrong
procedure or wrong implant event.
G8913: Patient documented not to have experienced a wrong site, wrong side, wrong patient,
wrong procedure or wrong implant event.
G8907: Patient documented not to have experienced any of the following events: a burn prior to
discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong procedure
or wrong implant event; or a hospital transfer or hospital admission upon discharge from
the facility.
Note: If using code G8912 or G8913, do not use code G8907.
DEFINITIONS:
Admission - completion of registration upon entry into the facility.
Wrong - not in accordance with intended site, side, patient, procedure or implant.
SELECTION BASIS:
“Surgery performed on the wrong body part,” “surgery performed on the wrong patient,” and “wrong
surgical procedure performed on a patient” have all been endorsed as serious reportable surgical
events by NQF. This outcome measure serves as an indirect measure of providers' adherence to
The Joint Commission, 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 forty professional medical associations
and organizations. To encompass the outcomes of all key identification verifications, the ASC
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 11
Quality Collaboration's measure incorporates not only wrong site, wrong side, wrong patient and
wrong procedure, but also wrong implant in its specifications.
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.
REFERENCES
�� 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.
�� American Academy of Ophthalmology. Recommendations of American Academy of
Ophthalmology Wrong-Site Task Force.
http://one.aao.org/ce/practiceguidelines/patient_content.aspx?cid=d0db838c-2847-4535-
baca-aebab3011217.
�� American Academy of Orthopaedic Surgeons. Wrong-Site Surgery. Information Statement
1015 http://www.aaos.org/about/papers/advistmt/1015.asp.
�� American College of Obstetricians and Gynecologists. ACOG committee opinion #464:
patient safety in the surgical environment. Obstet Gynecol. 2010; 116(3):786-790.
�� American College of Surgeons. [ST-41] Statement on ensuring correct patient, correct site,
and correct procedure surgery http://www.facs.org/fellows_info/statements/st-41.html
�� AORN. AORN Position Statement on Preventing Wrong-Patient, Wrong-Site, Wrong-
Procedure Events.
http://www.aorn.org/PracticeResources/AORNPositionStatements/PositionCorrectSiteSurge
ry/.
�� Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC:
National Academy Press, 2000.
�� Joint Commission. 2011 National Patient Safety Goals.
http://www.jointcommission.org/standards_information/npsgs.aspx.
�� National Quality Forum. Serious Reportable Events in Healthcare – 2006 Update: A
Consensus Report. March 2007.
�� World Health Organization. WHO Guidelines for Safe Surgery 2009.
http://whqlibdoc.who.int/publications/2009/9789241598552_eng.pdf.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 12
Measure Title: Hospital Transfer/Admission
MEASURE ID #: ASC-4
REPORTING MECHANISM:
Medicare-Fee-for-Service Claims
DESCRIPTION:
ASC admissions (patients) who are transferred or admitted to a hospital upon discharge from the
ASC.
DENOMINATOR:
All ASC admissions
Inclusions: All ASC admissions.
Exclusions: None
NUMERATOR:
ASC admissions requiring a hospital transfer or hospital admission upon discharge from the ASC.
Inclusions: ASC admissions requiring a hospital transfer or hospital admission upon
discharge from the ASC.
Exclusions: None
Numerator Quality-Data Coding Options for Reporting:
G8914: Patient documented to have experienced a hospital transfer or hospital admission upon
discharge from ASC.
G8915: Patient documented not to have experienced a hospital transfer or hospital admission
upon discharge from ASC.
G8907: Patient documented not to have experienced any of the following events: a burn prior to
discharge; a fall within the facility; wrong site, wrong side, wrong patient, wrong procedure
or wrong implant event; or a hospital transfer or hospital admission upon discharge from
the facility.
Note: If using code G8914 or G8915, do not use code G8907.
DEFINITIONS:
Admission - completion of registration upon entry into the facility.
Hospital Transfer/Admission - any transfer/admission from an ASC directly to an acute care
hospital including hospital emergency room.
Discharge - occurs when the patient leaves the confines of the ASC.
SELECTION BASIS:
The need for transfer/admission is an unanticipated outcome and could be the result of insufficient
rigor in patient or procedure selection. Hospital transfers/admissions can result in unplanned cost
and time burdens that must be borne by patients and payers.
Selected states have expressed an interest in the public reporting of such events. While hospital
transfers and admissions undoubtedly represent good patient care when necessary, high rates
may be an indicator that practice patterns or patient selection guidelines are in need of review.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 13
CLINICAL RECOMMENDATION STATEMENTS:
No clinical practice guidelines specifically addressing transfers or admissions from ASCs to acute
care hospitals are available at this time.
REFERENCES
�� Coley K et al. Retrospective evaluation of unanticipated admissions and readmissions after
same day surgery and associated costs. J Clin Anesth. 2002;14:349-353.
�� Lin D, Dalgorf D, Witterick IJ. Predictors of unexpected hospital admissions after outpatient
endoscopic sinus surgery: retrospective review. J Otolaryngol Head Neck Surg. 2008
Jun;37(3):309-11.
�� Hofer RE, Kai T, Decker PA, Warner DO. Obesity as a risk factor for unanticipated
admissions after ambulatory surgery. Mayo Clin Proc. 2008 Aug;83(8):908-16.
�� Tewfik MA, Frenkiel S, Gasparrini R, Zeitouni A, Daniel SJ, Dolev Y, Kost K, Samaha M,
Sweet R, Tewfik TL. Factors affecting unanticipated hospital admission following
otolaryngologic day surgery. J Otolaryngol. 2006 Aug;35(4):235-41.
�� Shirakami G, Teratani Y, Namba T, Hirakata H, Tazuke-Nishimura M, ***uda K. Delayed
discharge and acceptability of ambulatory surgery in adult outpatients receiving general
anesthesia. J Anesth. 2005;19(2):93-101.
�� Lau H, Brooks DC. Predictive factors for unanticipated admissions after ambulatory
laparoscopic cholecystectomy. Arch Surg. 2001 Oct;136(10):1150-3.
�� Junger A, Klasen J, Benson M, Sciuk G, Hartmann B, Sticher J, Hempelmann G. Factors
determining length of stay of surgical day-case patients. Eur J Anaesthesiol. 2001
May;18(5):314-21.
�� Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery—a prospective
study. Can J Anaesth. 1998 Jul;45(7):612-9.
�� Margovsky A. Unplanned admissions in day-case surgery as a clinical indicator for quality
assurance. Aust N Z J Surg. 2000 Mar;70(3):216-20.
�� Lledó JB, Planells M, Espí A, Serralta A, García R, Sanahuja A. Predictive model of failure
of outpatient laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech. 2008
Jun;18(3):248-53.
�� Shaikh S, Chung F, Imarengiaye C, Yung D, Bernstein M. Pain, nausea, vomiting and
ocular complications delay discharge following ambulatory microdiscectomy. Can J
Anaesth. 2003 May;50(5):514-8.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 14
Measure Title: Prophylactic Intravenous (IV) Antibiotic Timing
MEASURE ID #: ASC-5
REPORTING MECHANISM:
Medicare-Fee-for-Service Claims
DESCRIPTION:
Intravenous (IV) antibiotics given for prevention of surgical site infection were administered on
time.
DENOMINATOR:
All ASC admissions with a preoperative order for a prophylactic IV antibiotic for prevention of
surgical site infection.
Inclusions: All ASC admissions with a preoperative order for a prophylactic IV antibiotic for
prevention of surgical site infection.
Exclusions: ASC admissions with a preoperative order for a prophylactic IV antibiotic for
prevention of infections other than surgical site infections (e.g. bacterial endocarditis); ASC
admissions with a preoperative order for a prophylactic antibiotic not administered by the
intravenous route.
NUMERATOR:
Number of ASC admissions with an order for a prophylactic IV antibiotic for prevention of surgical
site infection who received the prophylactic antibiotic on time.
Inclusions: All ASC admissions with a preoperative order for a prophylactic IV antibiotic for
prevention of surgical site infection.
Exclusions: None
Numerator Quality-Data Coding Options for Reporting:
G8916: Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis,
antibiotic initiated on time.
G8917: Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis,
antibiotic not initiated on time.
G8918: Patient without preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis.
Note: The QDC of G8907 can be used If the patient did not experience any of the events for the
four outcome measures (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); this code would be used plus one of the codes above
for the prophylactic antibiotic timing measure for complete reporting of the 5 claims-based
measures.
DEFINITIONS:
Admission - completion of registration upon entry into the facility.
Antibiotic administered on time - Antibiotic infusion is initiated within one hour prior to the time of
the initial surgical incision or the beginning of the procedure (e.g., introduction of endoscope,
insertion of needle, inflation of tourniquet) or two hours prior if vancomycin or fluoroquinolones are
administered.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 15
Intravenous - Administration of a drug within a vein, including bolus, infusion or IV piggyback.
Order - a written order, verbal order, standing order or standing protocol.
Prophylactic antibiotic - an antibiotic prescribed with the intent of reducing the probability of an
infection related to an invasive procedure. For purposes of this measure, the following antibiotics
are considered prophylaxis for surgical site infections: Ampicillin/sulbactam, Aztreonam, Cefazolin,
Cefmetazole, Cefotetan, Cefoxitin, Cefuroxime, Ciprofloxacin, Clindamycin, Ertapenem,
Erythromycin, Gatifloxacin, Gentamicin, Levofloxacin, Metronidazole, Moxifloxacin, Neomycin and
Vancomycin.
SELECTION BASIS:
The CMS Surgical Infection Prevention performance measure states, “Surgical site infections occur
in 2-5 percent of clean extra-abdominal surgeries and up to 20 percent of intra-abdominal
surgeries. Each infection is estimated to increase a hospital stay by an average of 7 days and add
over $3,000 in charges (1992 data). Patients who develop surgical site infections are 60 percent
more likely to spend time in an ICU (intensive care unit), five times more likely to be readmitted to
the hospital, and have twice the incidence of mortality. Despite advances in infection control
practices, surgical site infections remain a substantial cause of morbidity and mortality among
hospitalized patients. Studies indicate that appropriate preoperative administration of antibiotics is
effective in preventing infection. Systemic and process changes that promote compliance with
established guidelines and standards can decrease infectious morbidity.”
There is no literature available on variation in adherence to recommended prophylactic IV antibiotic
timing among ASC providers. However, variability in the accuracy of timing of administration has
been demonstrated in other clinical settings.
CLINICAL RECOMMENDATION STATEMENTS:
This performance measure is aligned with current surgical infection prevention guidelines
recommending that prophylactic antibiotics be administered within one hour prior to surgical
incision, or within two hours prior to incision when vancomycin or fluoroquinolones are used.
REFERENCES
�� Horan T, Culver D, Gaynes R, Jarvis W, Edwards J, and Reid C. Nosocomial infections in
surgical patients in the United States, January 1986-June 1992. National Nosocomial
Infections Surveillance (NNIS) System. Infect Control HospEpidemiol. 1993; 14(2):73-80.
�� Marton W, Jarvis W, Culver D, and Haley R. Incidence and nature of endemic and epidemic
nosocomial infections. In: Bennett J, Brachman P, editor(s). Hospital infections. 3rd ed.
Boston, MA: Little, Brown and Co.; 1992. 577-596.
�� Kirkland K, Briggs J, Trivette S, Wilkinson W, and Sexton D. The impact of surgical-site
infections in the 1990s: attributable mortality, excess length of hospitalization, and extra
costs. Infect Control Hosp Epidemiol. 1999; 20(11):725-30.
�� Burke J. Maximizing appropriate antibiotic prophylaxis for surgical patients: an update from
LDS Hospital, Salt Lake City. Clin Infect Dis. 2001; 33(Suppl 2):S78-83.
�� Classen D et al. The timing of prophylactic administration of antibiotics and the risk of
surgical wound infection. NEJM. 1992; 326(5):281-286.
�� Silver A et al. Timeliness and use of antibiotic prophylaxis in selected inpatient surgical
procedures. The Antibiotic Prophylaxis Study Group. Am J Surg. 1996; 171(6):548-552.
�� Papaioannou N, Kalivas L, Kalavritinos J, and Tsourvakas S. Tissue concentrations of thirdgeneration
cephalosporins (ceftazidime and ceftriaxone) in lower extremity tissues using a
tourniquet. Arch Orthop Trauma Surg. 1994; 113(3):167-9.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 16
�� Dounis E, Tsourvakas S, Kalivas L, and Giamacellou H. Effect of time interval on tissue
concentrations of cephalosporins after tourniquet inflation. Highest levels achieved by
administration 20 minutes before inflation. Acta Orthop Scand. 1995; 66(2):158-60.
�� Friedrich L, White R, Brundage D, Kays M, Friedman R. The effect of tourniquet inflation on
cefazolin tissue penetration during total knee arthroplasty. Pharmacotherapy. 1990;
10(6):373-7.
�� Steinberg JP, Barun BI, Hellinger WC, Kusek L, Bozikis MR, Bush AJ, Dellinger EP, Burke
JP, Simmons B, Kritchevsky SB, Trial to reduce antimicrobial prophylaxis errors (TRAPE)
study group. Timing of antimicrobial prophylaxis and the risk of surgical site infections:
results from the trial to reduce antimicrobial prophylaxis errors. Ann Surg 2009; 250(1):10-6.
�� Forbes SS, Stephen WJ, Harper WL, Loeb M, Smith R, Christoffersen EP, McLean RF.
Implementation of evidence-based practices for surgical site infection prophylaxis: results of
a pre- and post intervention study. J Am Coll Surg. 2008 Sep; 207(3):336-41.
�� Koopman E, Nix DE, Erstad BL, Demeure MJ, Hayes MM, Ruth JT, Mattias KR. End-ofprocedure
cefazolin concentrations after administration for prevention of surgical-site
infection. Am J Health Syst Pharm. 2007 Sep; 64(18):1927-34.
�� Manniën J, van Kasteren ME, Nagelkerke NJ, Gyssens IC, Kullberg BJ, Wille JC, de Boer
AS. Effect of optimized antibiotic prophylaxis on the incidence of surgical site infection.
Infect Control Hosp Epidemiol. 2006; 27(12):1340-6.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 17
Measure Title: ASC Facility Volume Data on Selected ASC Surgical Procedures
MEASURE ID#: ASC-6
REPORTING MECHANISM:
Web-based tool on QualityNet
DESCRIPTION: The aggregate count of selected surgical procedures. Most ASC procedures fall
into one of eight categories: Cardiovascular, Eye, Gastrointestinal, Genitourinary, Musculoskeletal,
Nervous System, Respiratory, and Skin. The eight categories and corresponding HCPCS are
listed in the table below. The procedures and codes in Table 2 were selected based on recent ASC
data and update the procedure codes listed in the Calendar Year (CY) 2012 OPPS/ASC Final Rule
with Comment Period (CMS-1525-FC).
Measure ascertains response to the following question(s):
�� What was the aggregate count of selected surgical procedures per category?
Annual data submission period: July 1, 2013 – August 15, 2013 covering the performance
period January 1, 2012- December 31, 2012.
Table 2: Categories and HCPCS for ASC-6
Organ System CMS Procedure Category Surgical Procedure Codes
Cardiovascular Placement of long-term vascular
access catheter
36561
Vascular procedures to improve
blood flow to coronary (heart)
vessels
92980, 92981, 92982, 92984
Eye Organ transplant (eye) 65756, V2785
Laser procedure of eye 65855, 66761, 66821
Glaucoma procedures 66170, 66180
Cataract procedures 66982, 66984
Injection of eye 67028, J2778, J3300, J3396
Retina, macular and posterior
segment procedures
67041, 67042, 67210, 67228
Repair of surrounding eye structures 67900, 67904, 67917, 67924
Gastrointestinal GI endoscopy procedures 43239, 43235, 43248, 43249, 43251,
44361, 45330, 45331, 45378, 45380,
45381, 45383, 45384, 45385
Swallowing tube (esophagus) 43450
Hernia repair 49505
GI screening procedures G0105, G0121
Genitourinary Kidney stone fragmentation 50590
Bladder related procedures 52000, 52005, 52204, 52281, 52310,
52332,
Prostate biopsy 55700
Radiologic procedures (GU) 74420
Ultrasound procedures (GU) 76872
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 18
Musculoskeletal Joint or muscle aspiration or injection 20610
Removal of musculoskeletal implants 20680
Repair of tendons and ligaments 23412
Repair of foot, toes, fingers, and wrist 26055, 28270, 28285, 28296, , 29848
Removal of musculoskeletal lesion 26160
Joint arthroscopy 29824, 29826, 29827, 29880, 29881
Musculoskeletal drug injection J0585
Nervous Injection procedures in or around the
spine
62310, 62311, 64479, 64483, 64484,
64490, 64491, 64492, 64493, 64494,
64495, 64622, 64623, 64626, 64627,
G0260
Device implant 63650
Nerve decompression 64718
Repair of foot, toes, fingers, and wrist 64721
Respiratory Sinus procedure 31255
Skin Skin procedures 11042, 13132, 14040, 14060, 15260,
Q4101, Q4102, Q4106
Repair of surrounding eye structures 15823
Multi-system* Brachytherapy C2638, C2639, C2640, C2641
Cancer treatment C9257
*Multi-System: procedures that can be performed in more than one organ system.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 19
Measure Title: Safe Surgery Checklist Use
MEASURE ID #: ASC-7
REPORTING MECHANISM:
Web-based tool on QualityNet
Description: The use of a Safe Surgery Checklist for surgical procedures that includes safe
surgery practices during each of the three critical perioperative periods: the period prior to the
administration of anesthesia, the period prior to skin incision, and the period of closure of incision
and prior to the patient leaving the operating room.
Measure ascertains response to the following question(s):
�� Does/did your facility use a safe surgery checklist based on accepted standards of practice
at any time during the designated period? Yes/No
Annual data submission period: July 1, 2013 – August 15, 2013 covering the designated time
period January 1, 2012- December 31, 2012.
Examples for Safe Surgery Practices*
First critical point (period
prior to administering
anesthesia)
Second critical point (period
prior to skin incision)
Third critical point (period of
closure of incision and prior
to patient leaving the
operating room)
�� Verbal confirmation of
patient identity
�� Mark surgical site
�� Check anesthesia
machine/medication
�� Assessment of allergies,
airway and aspiration
risk
�� Confirm surgical team
members and roles
�� Confirm patient identity,
procedure and surgical
incision site
�� Administration of
antibiotic prophylaxis
within 60 minutes before
incision
�� Communication among
surgical team members
of anticipated critical
events
�� Display of essential
imaging as appropriate
�� Confirm the procedure
�� Complete count of
surgical instruments and
accessories
�� Identify key patient
concerns for recovery
and management of the
patient
*Hospital safe surgery checklist items are not limited to the examples listed in this table.
Centers for Medicare & Medicaid Services, Ambulatory Surgical Center Quality Reporting Program Page 20
APPENDIX A: DATA DEFINITIONS
Admission: Completion of registration upon entry into the facility.
Antibiotic administered on time: Antibiotic infusion is initiated within one hour prior to the time of
the initial surgical incision or the beginning of the procedure (e.g., introduction of endoscope,
insertion of needle, inflation of tourniquet) or two hours prior if vancomycin or fluoroquinolones are
administered.
Burn: Unintended tissue injury caused by any of the six recognized mechanisms: scalds, contact,
fire, chemical, electrical or radiation, (e.g. warming devices, prep solutions, electrosurgical unit or
laser).
Discharge: Occurs when the patient leaves the confines of the ASC.
Fall: A sudden, uncontrolled, unintentional, downward displacement of the body to the ground or
other object, excluding falls resulting from violent blows or other purposeful actions. (National
Center for Patient Safety)
Hospital transfer/admission: Any transfer/admission from an ASC directly to an acute care
hospital including hospital emergency room or emergency department.
Intravenous: Administration of a drug within a vein, including bolus, infusion or IV piggyback.
Order: A written order, verbal order, standing order or standing protocol.
Prophylactic antibiotic: An antibiotic prescribed with the intent of reducing the probability of an
infection related to an invasive procedure. For purposes of the Prophylactic IV Antibiotic Timing
measure, the following antibiotics are considered prophylaxis for surgical site infections:
Ampicillin/sulbactam, Aztreonam, Cefazolin, Cefmetazole, Cefotetan, Cefoxitin, Cefuroxime,
Ciprofloxacin, Clindamycin, Ertapenem, Erythromycin, Gatifloxacin, Gentamicin, Levofloxacin,
Metronidazole, Moxifloxacin, Neomycin and Vancomycin.
Quality Data Code (QDC): Non-payable Healthcare Common Procedure Coding System
(HCPCS) codes comprised of specified CPT Category II codes and/or G-codes that describe the
clinical action required by a measure's numerator.
Wrong: Not in accordance with intended site, side, patient, procedure or implant.
Additional information and resources, such as sample data collection sheets or logs and frequently
asked questions (FAQs) about the measures, can be found on the ASC Quality Collaboration
website at www.ascquality.org.