Ambulatory Surgical Center Quality Reporting (ASCQR) Program

Ambulatory Surgical Center Quality Reporting Specifications Manual
Release Notes Version: 9.0
Release Notes Completed: 06/01/2019
Guidelines for Using Release Notes
These Release Notes provide modifications to the Ambulatory Surgical Center Quality Reporting (ASCQR)
Specifications Manual. They are provided as a reference tool and are not intended to be used as program
abstraction tools. Please refer to the ASCQR Specifications Manual for the complete and current technical
specifications and abstraction information.
The notes are organized to follow the order of the Table of Contents. Within each topic section, a row
represents a change that begins with general changes and is followed by data elements in alphabetical order.
The implementation date is 01/01/2020, unless otherwise specified. The row headings are described below:
•

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

•

Rationale – Provided for the change being made.

•

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

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ASC Release Notes version 9.0
The notes in the tables below are organized to follow the Table of Contents in the Specifications Manual.

Measure Information Forms
Impacts: ASC-12
Rationale: Updated cover page performance period to be in accordance with CY2022 payment
determination.
Description of Change:
From: CMS will use the measure results in the Ambulatory Surgical Center Quality Reporting (ASCQR)
Program for payment determination in calendar year 2021. Beginning with payment determination year
2020, CMS will calculate the measure with three years of claims data. For payment determination year 2021,
the performance period is January 2017 through December 2019.
To: CMS will use the measure results in the Ambulatory Surgical Center Quality Reporting (ASCQR)
Program for payment determination in calendar year 2022. Beginning with payment determination year
2020, CMS will calculate the measure with three years of claims data. For payment determination year 2022,
the performance period is January 2018 through December 2020.
______________________________________________________________________________________
Impacts: ASC-13
Rationale: Update measure title to reflect naming convention in the 2017 OPPS/ASC Final Rule
Description of Change:
From: Normothermia
To: Normothermia Outcome
_______________________________________________________________________________________
Impacts: ASC-17
Rationale: In the 2018 OPPS Final Rule, it was finalized for ASC-17 Hospital Visits After Orthopedic
Ambulatory Surgical Center Procedure to be a required measure in the ASC Quality Reporting Program for
CY 2022 Payment Determination and subsequent years.
Description of Change:
Add: ASC-17 Measure Information Form

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ASC Release Notes version 9.0
_______________________________________________________________________________________
Impacts: ASC-18
Rationale: In the 2018 OPPS Final Rule, it was finalized for ASC-18 Hospital Visits After Urology
Ambulatory Surgical Center Procedures to be a required measure in the ASC Quality Reporting Program for
CY 2022 Payment Determination and subsequent years.
Description of Change:
Add: ASC-18 Measure Information Form

Appendix A: Tools and Resources
Impacts: ASC-9, ASC-11, and ASC-13
Rationale: To remove the Glossary of Terms due to majority of terms not applicable to the program at this
time. Replace with abstraction tools so that stakeholders access one resource for completing data submission.
Description of Change:
Remove: Glossary of Terms
Add: Abstraction Tools and Resources

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Ambulatory Surgical Center Quality Reporting
Specifications Manual
Version 9.0
Encounter Dates: 01-01-20 (1Q20) through 12-31-20 (4Q20)

OMB # 0938-1270 Expiration Date: 01/31/2022

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

Table of Contents
Acknowledgement ................................................................................................................................................. ii
Program Background and Requirements .......................................................................................................... iii
Section 1: Measure Information Form Introduction ...................................................................................... 1-1
Measure Information Forms
ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy
in Average Risk Patients ......................................................................................................................... 1-2
ASC-11: Cataracts – Improvement in Patient’s Visual Function within 90 Days Following
Cataract Surgery.................................................................................................................................... 1-4
ASC-12: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy......................... 1-6
ASC-13: Normothermia Outcome ..................................................................................................................... 1-11
[

]

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

[

ASC-17: Hospital Visits After Orthopedic Ambulatory Surgical Center Procedures ....................................... 1-16

]

ASC-18: Hospital Visits After Urology Ambulatory Surgical Center Procedures ........................................... 1-21

]

Section 2: Sampling Specifications ................................................................................................................. 2-25
Section 3: Quality-Data Transmission .......................................................................................................... 3-26
Appendix A: Tools and Resources................................................................................................................. A-28
Appendix B: Preview Section ..........................................................................................................................B-38

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Acknowledgement
The Ambulatory Surgical Center Quality Reporting (ASCQR) Specifications Manual was developed by the
Centers for Medicare & Medicaid Services (CMS) to provide a uniform set of quality measures to be
implemented in ASC settings. The primary purpose of these measures is to promote high quality care for
patients receiving services in ASC settings.
No royalty or use fee is required for copying or reprinting this manual, but the following are required as a
condition of usage: 1) disclosure that the ASCQR Specifications Manual is periodically updated, and that the
version being copied or reprinted may not be up-to-date when used unless the copier or printer has verified
the version to be up-to-date and affirms that, and 2) users participating in the Ambulatory Surgical Center
Quality Reporting Program (ASCQR Program) are required to update their software and associated
documentation based on the published manual production timelines.
Example Acknowledgement: The ASCQR Specifications Manual [Version xx, Month, Year] is periodically
updated by the Centers for Medicare & Medicaid Services. Users of the ASCQR Specifications Manual must
update their software and associated documentation based on the published manual production timelines.
CPT® only copyright 2019 American Medical Association. All rights reserved.
CPT® is a registered trademark of the American Medical Association.

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

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Program Background and Requirements
CMS Quality Initiatives
Background
In November 2001, Health & Human Services’ (HHS) Secretary Tommy G. Thompson announced The
Quality Initiative, his commitment to assure quality healthcare for all Americans through published
consumer information coupled with healthcare quality improvement support through Medicare’s Quality
Improvement Organizations (QIOs). The Quality Initiative was launched nationally in 2002 as the Nursing
Home Quality Initiative (NHQI) and expanded in 2003 with the Home Health Quality Initiative (HHQI) and
the Hospital Quality Initiative (HQI). These initiatives are part of a comprehensive look at quality of care
that includes hospitals, nursing homes, home health agencies, and physician offices. These efforts have
continued to expand under subsequent Secretaries through support and expansion of activities to support
healthcare transparency and value-driven healthcare.
The Medicare Improvements and Extension Act under Division B of Title I of the Tax Relief and HealthCare
Act (MIEA-TRHCA) of 2006 (Pub. L. 109-432), enacted on December 20, 2006, made changes in the
Outpatient Prospective Payment Systems (OPPS). The Centers for Medicare & Medicaid Services (CMS)
became statutorily required in the Calendar Year (CY) 2008 OPPS/ASC Final Rule to have a program under
which ASCs will report data on the quality of ASC care using standardized measures to receive the full
annual update to the ASC payment rate. The program established under the CY 2012 OPPS/ASC Final Rule
with Comment Period (CMS-1525-FC) and supported by this manual is the Ambulatory Surgical Center
Quality Reporting Program (ASCQR Program). The measures described in this manual will expand as
additional priority areas for quality improvements in ASC settings are identified and will be designed to
evaluate the diversity of services and clinical topics provided to adult patients in ASC settings. The claimsbased measures ASC-1 through ASC-4, adopted by CMS for the ASCQR Program, were originally
developed by the ASC Quality Collaboration and are the intellectual property of the ASC Quality
Collaboration. Additional information about the ASC quality measures endorsed by the National Quality
Forum (NQF) is available in the ASC Quality Collaboration Implementation Guide (www.ascquality.org).
Measures ASC-1 through ASC-4 have been retained in the ASC Quality Reporting Program; however, data
collection has been suspended beginning with the CY 2021 payment determination until further action in
rulemaking, with the goal of updating the data submission method.
Objective
The ASCQR Program uses a variety of tools to stimulate and support a significant improvement in the
quality of ASC care. This initiative aims to refine and standardize ASC data collection, data transmission,
and performance measures in order to construct a robust, prioritized, and standard quality outpatient measure
set for ASCs. The goal is for all private and public purchasers, oversight and accrediting entities, and payers
and providers of ASC care to use these same measures in their national public reporting activities. Quality
improvement support, collaborations, standardization, and assuring compliance with Medicare Conditions of
Participation (CoPs) are important additional tools in achieving this objective.

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Program Requirements
ASCs that do not meet program requirements, which include reporting of quality measure data for the
ASCQR Program, may receive a two percent reduction in their ASC payment update. ASCQR Program
requirements apply to all entities subject to the ASC Fee Schedule (ASCFS). The definition of an ASC can
be found in the Claims Processing Manual, Chapter 14, Section 10.1, located at (www.cms.hhs.gov).
Data Collection and Submission
Data for claims-based measures included in this specifications manual are captured from Medicare Part B
fee-for-service (FFS) claims submitted by the ASC during required reporting periods. Medicare Part B FFS
patients include Medicare Railroad Retirement Board patients and Medicare Secondary payer patients.
Medicare Advantage patients are not included for reporting purposes. For claims-based measures, the
reporting period refers to the dates of service, not date of submission. For example, if a service was provided
on December 30, 2020 with claim submission on January 1, 2021, this claim would be included in the 2022
payment determination.
Measures Submitted via a Web-Based Tool
Data for ASC-9, ASC-11 (ASC-11 is a voluntary measure), ASC-13, and ASC-14 are to be submitted using
a web-based tool located on the QualityNet Secure Portal at www.QualityNet.org.
Annual Data Submission Period: See the timeline posted to QualityNet.org for these measures.
Submission Instructions:
Data entry will be achieved through the secure side of QualityNet.org via an online tool available to
authorized users. After logging into the secure portal:]
•
•
•
•
•

Select Hospital Quality Reporting: from the Quality Programs drop-down menu to open the
“Quality Reporting System: My Tasks” page.
Select the Manage Measures option for view/edit of Structural/Web-Based Measures.
Select Ambulatory Surgical Center Web-Based Measures.
Select the appropriate payment year from the drop-down menu.
Select the measure for submitting data, saving each measure as the data are entered.
o Repeat the process for each required measure until data entry for all required measures are
complete (select the measure, submit measure data, and save the data). Facilities that do not
have data for a required measure should report a “zeros” in both the Numerator and
Denominator.
o All measure data must be submitted by the deadline.

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

Fewer Than 240 Rule
CMS determined that some ASCs have relatively small numbers of Medicare claims and instituted a claims
threshold for ASCs with fewer than 240 Medicare claims (primary plus secondary payer) per year. For

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example, an ASC with fewer than 240 Medicare claims in CY 2019 (for the CY 2021 payment determination
year) would not be required to participate in the ASCQR Program in CY 2020 (for the CY 2022 payment
determination year).
Public Reporting
The Secretary of Health and Human Services must establish procedures to make data collected under the
ASC Quality Reporting Program publicly available and to supply facilities the opportunity to review their
data prior to publication. Details on the ability to withdraw and not have data publicly reported, the
extraordinary circumstance exceptions request process, and the reconsideration request process were
finalized in the FY 2013 IPPS/LTCH final rule.
Related National Activities
National Quality Forum (NQF)
The NQF has approved a set of national voluntary consensus standards for measuring the quality of hospital
care. These measures will permit consumers, providers, purchasers, and quality improvement professionals
to evaluate and compare the quality of care in a variety of healthcare settings across the nation by using a
standard set of measures. Measures that are endorsed by NQF are denoted as such on the measure
information forms.
Measures Management System
The Measures Management System (MMS) is a set of processes and decision criteria used by CMS to
oversee the development, implementation, and maintenance of healthcare quality measures. CMS recognizes
the need for quality measures of the highest caliber, maintained throughout their life cycle to ensure they
retain the highest level of scientific soundness, importance, feasibility, and usability. Through the use of a
standardized process with broadly recognized criteria, the MMS ensures that CMS will have a coherent,
transparent system for measuring the quality of care delivered to its beneficiaries.
Paperwork Reduction Act (PRA)
PRA Disclosure
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-1270. The time required to complete this information collection is estimated
to average 15 minutes per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, MD
21244-1650.
Expiration Date: 01-31-2022

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Measure Information Form Introduction
Measure Information Form (MIF) Format
Measure Title – The specific national ASC quality measure.
Measure ID # – A unique alphanumeric identifier assigned to the measure. Information associated with a
measure is identified by this alphanumeric number (i.e., ASC-9, ASC-13, ASC-14, etc.).
Quality Reporting Option – Indicates what is being evaluated by the measure.
• Outcome: A measure that indicates the result of performance (or non-performance) of a function(s) or
process(es).
• Process: A measure used to assess a goal-directed, interrelated series of actions, events, mechanisms, or
steps, such as a measure of performance that describes what is done to, for, or by patients, as in
performance of a procedure.
• Measures Submitted via a Web-based Tool - A measure used to assess a goal-directed, interrelated
series of actions, events, mechanisms, or steps with data entry achieved through the secure side of
QualityNet.org via an online tool available to authorized users.
Description – A brief explanation of the measure’s focus, such as the activity or the area on which the
measure centers attention (e.g., This measure is used to assess the percentage of cataract surgery patients
who have an unplanned anterior vitrectomy).
Denominator Statement – Represents the population evaluated by the performance measure.
• Included Population in Denominator: Specific information describing the population(s)
comprising the denominator, not contained in the denominator statement, or not applicable.
• Excluded Population in Denominator: Specific information describing the population(s)
that should not be included in the denominator, or none.
Numerator Statement – Represents the portion of the denominator that satisfies the conditions of the
performance measure.
• Included Population in Numerator: Specific information describing the population(s) comprising the
numerator, not contained in the numerator statement, or not applicable.
• Excluded Population in Numerator: Specific information describing the population(s) that should not
be included in the numerator, or none.
Data Sources – The documents that typically contain the information needed to determine the numerator and
denominator.
Definitions – Specific definitions for the terms included in the numerator and denominator statements.
Selection Basis – The reason for performing a specified process to improve the quality of care outcome. This
may include specific literature references, evidence-based information, expert consensus, etc.
Clinical Recommendation Statements – Supporting literature statements for the specified quality of care
measure.
Selected References – Specific literature references that are used to support the importance of the
performance measure.
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Measure Information Form
Measure Title: Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in
Average Risk Patients
Measure ID #: ASC-9
Quality Reporting Option: Measures submitted via a web-based tool
Description: Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without
biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat
colonoscopy documented in their colonoscopy report.
Numerator Statement: Patients who had a recommended follow-up interval of at least 10 years for repeat
colonoscopy documented in their colonoscopy report.
Denominator Statement: All patients aged 50 to 75 years of age receiving screening colonoscopy without
biopsy or polypectomy.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 50 and ≤ 75 on date of encounter
and
ICD-10-CM Diagnosis code: Z12.11
and
CPT or HCPCS: 44388, 45378, G0121
without
CPT Category I Modifiers: 52, 53, 73, 74
without
ICD-10-CM Diagnosis codes: Z83.71, Z86.010, Z80.0, Z85.038
Denominator Exclusions:
• Documentation of medical reason(s) for not recommending at least a 10-year follow-up interval (e.g.,
inadequate prep, familial or personal history of colonic polyps, patient had no adenoma and age is ≥66
years old, or life expectancy <10 years, other medical reasons). Medical reason(s) are at the discretion of
the physician. Documentation indicating no follow-up colonoscopy is needed or recommended is only
acceptable if the patient’s age is documented as ≥66 years old, or life expectancy <10 years.
Documentation of a medical condition or finding can be used as a medical reason(s) for denominator
exclusion purposes only if the documented recommended follow-up interval is less than 10 years.
Examples:
 Diverticulitis documented in the medical record and a follow-up interval of 5 years in the
colonoscopy report.
 Family history of colon cancer and a follow-up interval of 3 years documented in the
colonoscopy report.
 Less than adequate prep documented in the medical record with a repeat colonoscopy in 3
years in the colonoscopy report.
]

Annual Data Submission Period: See the timeline posted to QualityNet.org for this measure; select
Ambulatory Surgical Centers and then Data Submission in the drop-down menu. Data entry will be achieved
through the secure side of QualityNet.org via an online tool available to authorized users.

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

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Measure Information Form
Measure Title: Cataracts – Improvement in Patient’s Visual Function within 90 Days Following Cataract
Surgery
Measure ID #: ASC-11*
Quality Reporting Option: Measure submitted via a web-based tool
Description: Percentage of patients aged 18 years and older who had cataract surgery and had improvement
in visual function achieved within 90 days following the cataract surgery, based on completing a preoperative and post-operative visual function survey.
Numerator Statement: Patients 18 years and older who had improvement in visual function achieved
within 90 days following cataract surgery, based on completing both a pre-operative and post-operative
visual function instrument.
Denominator Statement: All patients aged 18 years and older who had cataract surgery and completed both
a pre-operative and post-operative visual function survey.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years
and
CPT (with or without modifiers): 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984
Excluded Population: Patients who did not complete both a pre-operative and post-operative survey
Annual Data Submission Period: See the timeline posted to QualityNet.org for this measure; select
Ambulatory Surgical Centers and then Data Submission in the drop-down menu. Data entry will be achieved
through the secure side of QualityNet.org via an online tool available to authorized users.
Data Collection Approach: Include procedures performed from the beginning of the reporting year through
90 days prior to the end of the reporting period. This will allow the post-operative period to occur.
Additional Instructions: Definition for Survey: An appropriate data collection instrument is an assessment
tool that has been validated for the population for which it is being used; this measure utilizes a visual
function survey. While it is recommended that the facility obtain the survey results from the appropriate
physician or optometrist, the surveys can be administered by the facility via phone, mail, email, or during
clinician follow-up. For this measure, the same data collection instrument (i.e., survey) must be used preoperatively and post-operatively.
Examples of tools for visual function assessment include, but are not limited to, National Eye InstituteVisual Function Questionnaire (VFQ- http://www.rand.org/health/surveys_tools/vfq.html), the Visual
Function (VF)-14, the modified VF-8, the Activities of Daily Vision Scale (ADVS), the Catquest, and the
modified Catquest-9. For each of the VF tools (VF-14 or VF-8R), all questions have equal weight; only nonmissing questions are included, and the total weight is 100.
Definition of Performance Met: Improvement in visual function achieved within 90 days following cataract
surgery (G0913).

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Definition of Performance Not Met: Improvement in visual function not achieved within 90 days following
cataract surgery (G0915).
Denominator Exception: Patient care survey was not completed by patient (G0914).
*Finalized in the CY 2015 OPPS/ASC final rule, ASCs have the option to voluntarily collect and submit data
for ASC-11 for the CY 2017 payment determination and subsequent years. All data submitted voluntarily
will be publicly reported as discussed in the CY 2014 OPPS/ASC proposed rule (Vol. 78, No. 139 Proposed
Rule, pp.43664, 43669).

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Centers for Medicare & Medicaid Services (CMS)
Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy
Introduction
This section of the manual includes the Measure Information Form (MIF) for the CMS Facility 7-Day RiskStandardized Hospital Visit Rate after Outpatient Colonoscopy measure. This is an administrative claimsbased measure, so there is no data abstraction responsibility on the part of the facility. The measure includes
outpatient colonoscopies performed among Medicare Fee-for-Service (FFS) beneficiaries aged ≥ 65 years.
CMS will use the measure results in the Ambulatory Surgical Center Quality Reporting (ASCQR) Program
for payment determination in calendar year 2022. Beginning with payment determination year 2020, CMS
will calculate the measure with three years of claims data. For payment determination year 2022, the
performance period is January 2018 through December 2020.
[

This measure was developed by a team of clinical and statistical experts from the Yale New Haven Health
Services Corporation/Center for Outcomes Research and Evaluation (YNHHSC/CORE), under contract to
CMS. The measure is currently endorsed by the National Quality Forum (NQF #2539).
The aim of the MIF is to provide transparency of the measure methodology to the facility and vendor
communities. Additional background information about the measure methodology can be found in the
Measure Updates and Specifications Report available on the Measure Methodology QualityNet page
(http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid
=1228775214597). CMS provides a new report each year to align with the most current calendar year. For
example, the 2018 Measure Updates and Specifications Report will align with a performance period ending
in calendar year 2018. If the reevaluation report associated with the performance period of this MIF is not yet
available, it is sufficient to use the most recent report. Please submit questions about the measure to the
QualityNet Question and Answer Tool here: https://cms-ocsq.custhelp.com/.
CMS calculates a facility-level risk-standardized unplanned hospital visit rate for all eligible facilities.
Facilities and their ORYX® Vendors do not have sufficient data to produce facilities’ risk-standardized
results. CMS inpatient and outpatient claims data are used to determine whether a beneficiary has had an
unplanned hospital visit to any acute care hospital within 7 days of the outpatient colonoscopy. In addition,
CMS extracts and utilizes physician office, inpatient, and outpatient claims data from the year prior to the
colonoscopy, as well as claims data from the colonoscopy, to risk adjust the facility-level outcome rates.

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Measure Information Form (MIF)
Performance Measure Name: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient
Colonoscopy
Measure ID #: ASC-12
Measure Set: CMS Outcome Measures (Claims-Based)
Description: The Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy
Measure, hereafter referred to as the colonoscopy measure, estimates a facility-level rate of riskstandardized, all-cause, unplanned hospital visits within 7 days of an outpatient colonoscopy among
Medicare Fee-for-Service (FFS) patients aged 65 years and older.
Rationale: The colonoscopy measure will reduce adverse patient outcomes associated with preparation for
colonoscopy, the procedure itself, and follow-up care by capturing and making more visible to providers and
patients all unplanned hospital visits following the procedure. The measure score will assess quality and
inform quality improvement.
Type of Measure: Outcome
Improvement Noted As: A decrease in the facility-level risk-standardized unplanned hospital visit rate.
Lower rate indicates better quality.
Numerator Statement:
The colonoscopy measure does not have a traditional numerator and denominator like a core process
measure (e.g., percentage of adult patients with diabetes aged 18-75 years receiving one or more hemoglobin
A1c tests per year); thus, we are using this field to define the outcome. The calculation of the rate is defined
under the Measure Calculation below.
The outcome for this measure is all-cause, unplanned hospital visits within 7 days of an outpatient
colonoscopy. The measure defines a hospital visit as any emergency department (ED) visit, observation stay,
or unplanned inpatient admission.
Denominator Statement:
The target population for this measure includes low-risk colonoscopies performed in the outpatient setting
for Medicare FFS patients aged 65 years and older. For implementation in the Ambulatory Surgical Center
Quality Reporting (ASCQR) Program, the measure will be calculated among Ambulatory Surgical Centers
(ASCs).
Included Populations:
Outpatient colonoscopies for Medicare FFS patients aged 65 years and older. Medicare FFS beneficiaries
with an outpatient colonoscopy are included if the patient has been enrolled in Part A and Part B Medicare
for the 12 months prior to the date of procedure to ensure a full year of administrative data for risk
adjustment.
The measure is focused on low-risk colonoscopies. Cohort codes are located in the data dictionary that
accompanies the Measure Updates and Specifications Report, available on the Measure Methodology
QualityNet page
(http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid

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=1228775214597). (Note that in prior years, all measure codes are located within the Measure Updates and
Specifications Reports.)
The measure does not include colonoscopy Current Procedural Terminology (CPT®) procedure codes that
reflect fundamentally higher-risk or different procedures. Qualifying colonoscopies billed with a concurrent
high-risk colonoscopy procedure code are not included in the measure; the data dictionary that accompanies
the most recent Measure Updates and Specifications Report at the link above contains the complete listing of
all high-risk procedure codes.
Cohort Exclusions (excluded colonoscopies):
See the Measure Updates and Specifications Report available on the Measure Methodology QualityNet page
for detailed measure cohort exclusion criteria
(http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid
=1228775214597). The accompanying data dictionary contains the most current exclusion codes.
Admissions not counted in the outcome (“Planned admissions”):
Admissions identified as planned by the planned admission algorithm are not counted in the outcome. The
“algorithm” is a set of criteria for classifying admissions as planned using Medicare claims. The algorithm
identifies admissions that are typically planned and may occur within 7 days of an outpatient colonoscopy.
CMS based the planned admission algorithm on three principles:
1. A few specific, limited types of care are always considered planned (transplant surgery, maintenance
chemotherapy, rehabilitation);
2. Otherwise, a planned admission is defined as a non-acute admission for a scheduled procedure; and
3. Admissions for acute illness or for complications of care are never planned.
The planned admission algorithm uses a flowchart and four tables of procedures and conditions to
operationalize these principles and to classify inpatient admissions as planned. ED visits and observation
stays are never considered planned. The flowchart and tables are available in the Measure Updates and
Specifications Report available on the Measure Methodology QualityNet page
(http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid
=1228775214597).
Risk Adjustment:
The measure’s approach to risk adjustment is tailored to, and appropriate for, a publicly reported outcome
measure, as articulated in published scientific guidelines (Krumholz et al., 2006; Normand et al., 2007).
The measure uses a two-level hierarchical logistic regression model to estimate facility-level riskstandardized hospital visit rates. This approach accounts for the clustering of patients within facilities and
variation in sample size across facilities.
The risk-adjustment model includes 15 patient-level variables (age, concomitant upper GI endoscopy,
polypectomy during the procedure, and 12 comorbidity variables). The measure defines comorbidity
variables using condition categories (CCs), which are clinically meaningful groupings of the many thousands
of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis
codes. Certain CCs are considered possible complications of care; therefore, the measure does not risk-adjust
for them if they occur only at the time of the procedure. This is because only comorbidities that convey
information about the patient at the time of the procedure or in the 12 months prior, and not complications
that arose during the colonoscopy procedure, are included in the risk adjustment. The Measure Updates and
Specifications Report data dictionary contains complete definitions of risk factors and CCs that are
considered possible complications of care and are not risk adjusted for if they occur only at the time of the
procedure.
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Table 1: Patient-Level Risk-Adjustment Variables
Patient-Level
Risk-Adjusted Variables
Variables
Demographics
Procedural Factors

Comorbidities

Age (categorized; 65-69; 70-74; 75-79; 80-84; 85+)
Concomitant Endoscopy
Polypectomy during Procedure
Congestive Heart Failure
Ischemic Heart Disease
Stroke/Transient Ischemic Attack (TIA)
Chronic Lung Disease
Metastatic Cancer
Liver Disease
Iron Deficiency Anemia
Disorders of Fluid, Electrolyte, Acid Base
Pneumonia
Psychiatric Disorders
Drug and Alcohol Abuse/Dependence
Arrhythmia
Age Categorized x Arrhythmia Interaction

Note: The relationship between age and risk of a hospital visit within 7 days was modified by the presence or
absence of a cardiac arrhythmia (p-value for interaction < 0.001). Therefore, we included an interaction term
(age categorized x arrhythmia) in the final model.
Full details of the development of the risk-adjustment model for this measure are available at:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/Measure-Methodology.html.
Data Collection Approach: Medicare administrative claims and enrollment data.
Data Accuracy: The administrative claims data used to calculate the measure are maintained by CMS’
Office of Information Services. These data undergo additional quality assurance checks during measure
development and maintenance.
Measure Analysis Suggestions: None
Sampling: No
Data Reported As: Facility-level 7-day risk-standardized unplanned hospital visit rate following outpatient
colonoscopy.
Measure Calculation:
The measure estimates facility-level 7-day risk-standardized unplanned hospital visit rates using hierarchical
logistic regression modeling (a form of hierarchical generalized linear modeling [HGLM]). In brief, the
approach simultaneously models two levels (patient and facility) to account for the variance in patient
outcomes within and between facilities. At the patient level, the model adjusts the log-odds of a hospital visit
within 7 days of the procedure for age, procedural factors, and selected clinical covariates. At the facility
level, it estimates the facility-specific intercepts as arising from a normal distribution. The facility-specific
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intercept represents the underlying risk of a hospital visit within 7 days after a colonoscopy at that facility,
while accounting for patient risk. The facility-specific intercepts also account for the clustering (nonindependence) of patients within the same facility. If there were no differences among facilities, the facilityspecific intercepts would be identical across all facilities after adjusting for patient risk.
The statistical modeling approach is described fully in the original technical report:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/Measure-Methodology.html.
Selected References:
• Krumholz HM, Brindis RG, Brush JE, et al. Standards for Statistical Models Used for Public Reporting
of Health Outcomes: An American Heart Association Scientific Statement From the Quality of Care and
Outcomes Research Interdisciplinary Writing Group: Cosponsored by the Council on Epidemiology and
Prevention and the Stroke Council Endorsed by the American College of Cardiology Foundation.
Circulation. 2006; 113 (3): 456-462.
• Normand S-LT, Shahian DM. Statistical and Clinical Aspects of Hospital Outcomes Profiling. Stat Sci.
2007; 22 (2): 206-226.

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[Material inside brac kets ([a nd]) is new to t his Specificatio ns Ma nual version.]

Measure Information Form
[

Measure Title: Normothermia Outcome

]

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

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Rationale: Impairment of thermoregulatory control due to anesthesia may result in perioperative
hypothermia. Hypothermia, even when mild, is associated with consequences such as increased susceptibility
to infection, impaired coagulation, cardiovascular stress and cardiac complications, as well as post-anesthetic
shivering and thermal discomfort. Several methods to maintain normothermia are available.
There is no literature available on variation in rates of normothermia among ASC providers. However,
variability in maintaining normothermia has been demonstrated in other settings.
Clinical Practice Guidelines: This performance measure is aligned with current guidelines regarding
temperature management in patients undergoing general or neuraxial anesthesia lasting 60 minutes or more.
Measure ascertains response to the following question: What is the percentage of having surgical
procedures under general or neuraxial anesthesia of 60 minutes or more in duration are normothermic within
15 minutes of arrival in PACU?
Annual data submission period: January 1-May 15, 2020
References
American Society of PeriAnesthesia Nurses (ASPAN). ASPAN’s evidence-based clinical practice guideline
for the promotion of perioperative normothermia: second edition. J Perianesth Nurs. 2010;25(6):346-65.
Anderson DJ et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect
Control Hosp Epidemiol. 2014;35 Suppl 2: S66-88.
Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB,
Kasper EK, Kersten JR, Riegel B, Robb JF. ACC/AHA 2007 guidelines on perioperative cardiovascular
evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on
Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 2007;50: e159 –241.
Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative maintenance of normothermia reduces the
incidence of morbid cardiac events. A randomized clinical trial. JAMA. 1997;277(14): 1127-1134.
Frank SM, Beattie C, Christopherson R, et al. Unintentional hypothermia is associated with postoperative
myocardial ischemia. The Perioperative Ischemia Randomized Anesthesia Trial Study Group.
Anesthesiology. 1993;78(3):468-476.
Kurz A. Physiology of thermoregulation. Best Pract Res Clin Anaesthesiol. 2008;22(4):627-644.
Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound
infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med.
1996;334(19):1209- The quality measures presented in this guide are the intellectual property of the ASC
Quality Collaboration. 14 1215.
Kurz A, Sessler DI, Schroeder M, Kurz M. Thermoregulatory response thresholds during spinal anesthesia.
Anesth Analg. 1993;77(4):721-726.
Lista F, Doherty CD, Backstein RM, Ahmad J. The impact of perioperative warming in an outpatient
aesthetic surgery setting. Aesthet Surg J. 2012 Jul;32(5):613-20.

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Matsukawa T, Sessler DI, Sessler AM, et al. Heat flow and distribution during induction of general
anesthesia. Anesthesiology. 1995;82(3):662-673.
Morris RH. Operating room temperature and the anesthetized, paralyzed patient. Arch Surg. 1971;102(2):9597.
Ozaki M, Kurz A, Sessler DI, et al. Thermoregulatory thresholds during epidural and spinal anesthesia.
Anesthesiology. 1994;81(2):282-288.
Rajagopalan S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hypothermia on blood loss and
transfusion requirement. Anesthesiology. 2008;108(1):71-77.
Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A. Mild hypothermia increases blood loss and transfusion
requirements during total hip arthroplasty. Lancet. 1996;347(8997):289-292.
Scott EM, Buckland R. A systematic review of intraoperative warming to prevent postoperative
complications. AORN J. 2006;83(5):1090-1104, 1107-1113.

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[Material inside brac kets ([and]) is new to this Specification s Manual version.]

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

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

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Material inside brackets ( [ and ] ) is new to th is Specifications Manual version.
[Material inside brac kets ([a nd]) is new to t his Specificatio ns Ma nual version.]

Centers for Medicare & Medicaid Services (CMS)
Orthopedic Ambulatory Surgical Center Procedures Measure
Introduction
This section of the manual includes the Measure Information Form (MIF) for the Risk-Standardized Hospital
Visits within 7 days after Orthopedic Ambulatory Surgical Center (ASC) Procedures measure. Yale New
Haven Health Services Corporation – Center for Outcomes Research and Evaluation (CORE) developed the
measure for the Centers for Medicare & Medicaid Services (CMS) under a contract supporting the
development of ambulatory surgical center measures.
This is an administrative claims-based measure, so there is no data abstraction responsibility on the part of
the facility. CMS calculates a facility-level risk-standardized unplanned hospital visit rate for all eligible
facilities. Facilities and their ORYX® Vendors do not have sufficient data to produce facilities’ riskstandardized results. CMS inpatient and outpatient claims data are used to determine whether a beneficiary
has had an unplanned hospital visit to any acute care hospital within 7 days of the orthopedic surgery
procedure. In addition, CMS extracts and utilizes physician office, inpatient, and outpatient claims data from
the year prior to the surgery as well as claims data from the surgery to risk adjust the facility-level results.
CMS has finalized adoption of the measure into the Ambulatory Surgical Center Quality Reporting
(ASCQR) Program for payment determination beginning in calendar year 2022.
The information in the following MIF is being provided in the interest of transparency and to promote
understanding of the methodology on the part of the facility and vendor communities. Additional background
information about the measure methodology can be found in the measure technical report
(https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/Measure-Methodology.html). Questions and comments about the measure
should be directed to [email protected].

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Measure Information Form
Performance Measure Name: Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures
Measure ID #: ASC-17
Measure Set: CMS Outcome Measures (Claims-Based)
Description: The measure estimates a facility-level rate of risk-standardized, all-cause, unplanned hospital
visits within 7 days of an Orthopedic surgery at an ASC among Medicare fee-for-service (FFS) patients aged
65 years and older.
Rationale: Nearly 70% of all surgeries in the US are performed in an outpatient setting, with an expanding
number and variety of surgeries being performed at stand-alone ASCs (Cullen et al., 2009). This measure
will serve to improve transparency, inform patients and providers, and foster quality improvement efforts for
hospital visits following orthopedic surgery at ASCs.
Type of Measure: Outcome
Improvement Noted As: A decrease in the facility-level risk-standardized unplanned hospital visit rate.
Numerator Statement:
This outcome measure does not have a traditional numerator and denominator like a process measure (e.g.,
percentage of adult patients with diabetes aged 18-75 years receiving one or more hemoglobin A1c tests per
year); thus, we are using this field to define the outcome. The calculation of the rate is defined below under
Measure Calculation.
The outcome for this measure is all-cause, unplanned hospital visits within 7 days of orthopedic surgery at an
ASC. The measure defines a hospital visit as any emergency department (ED) visit, observation stay, or
unplanned inpatient admission.
Denominator Statement:
The target population for this measure is Medicare FFS patients aged 65 years and older undergoing
outpatient orthopedic surgeries, typically performed by an orthopedist, at ASCs.
Included Populations:
The target population is Medicare FFS patients aged 65 years and older undergoing outpatient orthopedic
surgeries at ASCs who have been enrolled in Part A and Part B Medicare for the 12 months prior to the date of
surgery to ensure adequate data for identifying comorbidities for risk adjustment.
The measure includes procedures that are routinely performed at ASCs, involve increased risk of postsurgery hospital visits, and are routinely performed by orthopedists. For a list of procedure codes included in
the measure cohort, see: Qualitynet.org > Ambulatory Surgical Centers > Measures > Orthopedic Measure
Dry Run > Measure Methodology.
Exclusions:
1. Surgeries for patients who survived at least 7 days but were not continuously enrolled in Medicare FFS
Parts A and B in the 7 days after the surgery. The measure excludes these patients to ensure all patients
have full data available for outcome assessment.

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Admissions Not Counted in the Outcome (“Planned Admissions”):
Admissions identified as planned by the planned admission algorithm are not counted in the outcome. The
“algorithm” is a set of criteria for classifying admissions as planned using Medicare claims. The algorithm
identifies admissions that are typically planned and may occur within 7 days of an outpatient surgery. CMS
based the planned admission algorithm on three principles:
1. A few specific, limited types of care are always considered planned (transplant surgery, maintenance
chemotherapy, rehabilitation);
2. Otherwise, a planned admission is defined as a non-acute admission for a scheduled procedure; and
3. Admissions for acute illness or for complications of care are never planned.
The planned admission algorithm uses a flowchart and four tables of procedures and conditions to
operationalize these principles and to classify inpatient admissions as planned. ED visits and observation
stays are never considered planned. The flowchart and tables are available in the measure technical report,
see: Qualitynet.org > Ambulatory Surgical Centers > Measures > Orthopedic Measure Dry Run > Measure
Methodology.
Risk Adjustment:
The measure’s approach to risk adjustment is tailored to, and appropriate for, a publicly reported outcome
measure as articulated in published scientific guidelines (Krumholz et al., 2006; Normand et al., 2007). The
measure uses a two-level hierarchical logistic regression model to estimate facility-level risk-standardized
hospital visit rates. This approach accounts for the clustering of patients within facilities and variation in
sample size across facilities. The measure adjusts for differences across facilities in patient demographics,
clinical factors, and surgery-related risk. Potential candidate risk factors were identified from related quality
measures and the literature; a preliminary list of risk factors was developed and then revised based on TEP
and expert clinical input.
The risk-adjustment model has 28 patient-level variables (age and 27 comorbidity variables) and work
relative value units (RVU) to adjust for surgical complexity (see Table 1). With the exception of morbid
obesity, opioid abuse, tobacco use disorder, and chronic anticoagulant use which we define using an
individual ICD-9-CM or ICD-10-CM diagnosis code, we define comorbidity variables using CMS Condition
Categories (CCs), which are clinically meaningful groupings of many thousands of ICD-9-CM and ICD-10CM diagnosis codes.
Table 1: Patient-Level Risk-Adjustment Variables
Patient-level variables

Risk-adjusted variables

Demographics

Age (years greater than 65)

Comorbidities

Cancer
Disorder of fluid/electrolyte/acid-base
Other gastrointestinal disorders
Bone/joint/muscle infections/necrosis
Rheumatoid and osteoarthritis
Dementia
Psychiatric disorders
Multiple sclerosis
Seizure disorders and convulsions
Congestive heart failure
Ischemic heart disease
Hypertension and hypertensive disease
Stroke

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Surgical Procedural
Complexity

Vascular disease
Chronic lung disease
Pneumonia
Other respiratory disorders
Chronic renal disease
Chronic ulcers
Head injury
Major traumatic fracture or internal injury
Major symptoms, abnormalities
Minor symptoms, signs, findings
Morbid obesity
Opioid abuse
Tobacco use
Chronic anticoagulant use
Work RVU

Full details of the development of the risk standardization model for this measure are available at:
Qualitynet.org > Ambulatory Surgical Centers > Measures > Orthopedic Measure Dry Run > Measure
Methodology.
Data Collection Approach: Medicare administrative claims and enrollment data
Data Accuracy: The administrative claims data used to calculate the measure are maintained by CMS’
Office of Information Services. These data undergo additional quality assurance checks during measure
development and maintenance.
Measure Analysis Suggestions: None
Sampling: No
Data Reported As: ASC-level 7-day risk-standardized, all-cause, unplanned hospital visit rate following
orthopedic surgery
Measure Calculation:
The measure estimates facility-level 7-day risk-standardized unplanned hospital visit rates using hierarchical
logistic regression modeling (a form of hierarchical generalized linear modeling [HGLM]). In brief, the
approach simultaneously models two levels (patient and facility) to account for the variance in patient
outcomes within and between facilities. At the patient level, the model adjusts the log-odds of a hospital visit
within 7 days of the surgery for age, procedural factors, and selected clinical covariates. At the facility level,
it estimates the facility-specific intercepts as arising from a normal distribution. The facility intercept
represents the underlying risk of a hospital visit within 7 days after an orthopedic surgery at an ASC while
accounting for patient risk. The facility-specific intercepts also account for the clustering (non-independence)
of patients within the same facility. If there were no differences among facilities, then after adjusting for
patient risk the facility-specific intercepts would be identical across all facilities.
The statistical modeling approach is described fully in the original technical report:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/Measure-Methodology.html.

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Selected References:
1. Cullen KA, Hall MJ, Golosinskiy A, National Center for Health Statistics. Ambulatory surgery in the
United States, 2006. US Department of Health and Human Services, Centers for Disease Control and
Prevention, National Center for Health Statistics; 2009.
2. Krumholz HM, Brindis RG, Brush JE, et al. Standards for statistical models used for public reporting
of health outcomes An American Heart Association scientific statement from the Quality of Care and
Outcomes Research Interdisciplinary Writing Group: Cosponsored by the Council on Epidemiology
and Prevention and the Stroke Council endorsed by the American College of Cardiology Foundation.
Circulation. 2006;113(3):456-462.
3. Normand S-LT, Shahian DM. Statistical and clinical aspects of hospital outcomes profiling.
Statistical Science. 2007;22(2):206-226.

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Encounter dates 01-01-20 (1Q20) through 12-31-20 (4Q20) v9.0
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Material inside brackets ( [ and ] ) is new to th is Specifications Manual version.

Centers for Medicare & Medicaid Services (CMS)
Urology Ambulatory Surgical Center Procedures Measure
Introduction
This section of the manual includes the Measure Information Form (MIF) for the Risk-Standardized Hospital
Visits within 7 days after Urology Ambulatory Surgical Center (ASC) Procedures measure. Yale New Haven
Health Services Corporation – Center for Outcomes Research and Evaluation (CORE) developed the
measure for the Centers for Medicare & Medicaid Services (CMS) under a contract supporting the
development of ambulatory surgical center measures.
This is an administrative claims-based measure, so there is no data abstraction responsibility on the part of
the facility. CMS calculates a facility-level risk-standardized unplanned hospital visit rate for all eligible
facilities. Facilities and their ORYX® Vendors do not have sufficient data to produce facilities’ riskstandardized results. CMS inpatient and outpatient claims data are used to determine whether a beneficiary
has had an unplanned hospital visit to any acute care hospital within 7 days of the urology surgery procedure.
In addition, CMS extracts and utilizes physician office, inpatient, and outpatient claims data from the year
prior to the surgery as well as claims data from the surgery to risk adjust the facility-level results.
CMS has finalized adoption of the measure into the Ambulatory Surgical Center Quality Reporting
(ASCQR) Program for payment determination beginning in calendar year 2022.
The information in the following MIF is being provided in the interest of transparency and to promote
understanding of the methodology on the part of the facility and vendor communities. Additional background
information about the measure methodology can be found in the measure technical report
(https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/Measure-Methodology.html). Questions and comments about the measure
should be directed to [email protected].

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Measure Information Form
Performance Measure Name: Hospital Visits after Urology Ambulatory Surgical Center Procedures
Measure ID #: ASC-18
Measure Set: CMS Outcome Measures (Claims-Based)
Description: The measure estimates a facility-level rate of risk-standardized, all-cause, unplanned hospital
visits within 7 days of a urology surgery at an ASC among Medicare fee-for-service (FFS) patients aged 65
years and older.
Rationale: Nearly 70% of all surgeries in the US are performed in an outpatient setting, with an expanding
number and variety of surgeries being performed at stand-alone ASCs (Cullen et al., 2009). This measure
will serve to improve transparency, inform patients and providers, and foster quality improvement efforts for
hospital visits following urology surgery at ASCs.
Type of Measure: Outcome
Improvement Noted As: A decrease in the facility-level risk-standardized unplanned hospital visit rate.
Numerator Statement:
This outcome measure does not have a traditional numerator and denominator like a process measure (e.g.,
percentage of adult patients with diabetes aged 18-75 years receiving one or more hemoglobin A1c tests per
year); thus, we are using this field to define the outcome. The calculation of the rate is defined below under
Measure Calculation.
The outcome for this measure is all-cause, unplanned hospital visits within 7 days of a urology surgery at an
ASC. The measure defines a hospital visit as any emergency department (ED) visit, observation stay, or
unplanned inpatient admission.
Denominator Statement:
The target population for this measure is Medicare FFS patients aged 65 years and older undergoing
outpatient urology surgeries, typically performed by a urologist, at ASCs.
Included Populations:
The target population is Medicare FFS patients aged 65 years and older undergoing outpatient urology
surgeries at ASCs who have been enrolled in Part A and Part B Medicare for the 12 months prior to the date
of surgery to ensure adequate data for identifying comorbidities for risk adjustment.
The measure includes surgeries that are routinely performed at ASCs, involve increased risk of post-surgery
hospital visits, and are routinely performed by urologists. For a list of procedure codes included in the
measure cohort, see: Qualitynet.org > Ambulatory Surgical Centers > Measures > Urology Measure Dry Run
> Measure Methodology.
Exclusions:
1. Surgeries for patients who survived at least 7 days but were not continuously enrolled in Medicare FFS
Parts A and B in the 7 days after the surgery. The measure excludes these patients to ensure all patients
have full data available for outcome assessment.

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Admissions Not Counted in the Outcome (“Planned Admissions”):
Admissions identified as planned by the planned admission algorithm are not counted in the outcome. The
“algorithm” is a set of criteria for classifying admissions as planned using Medicare claims. The algorithm
identifies admissions that are typically planned and may occur within 7 days of an outpatient surgery. CMS
based the planned admission algorithm on three principles:
1. A few specific, limited types of care are always considered planned (transplant surgery, maintenance
chemotherapy, rehabilitation);
2. Otherwise, a planned admission is defined as a non-acute admission for a scheduled procedure; and
3. Admissions for acute illness or for complications of care are never planned.
The planned admission algorithm uses a flowchart and four tables of procedures and conditions to
operationalize these principles and to classify inpatient admissions as planned. ED visits and observation
stays are never considered planned. The flowchart and tables are available in the measure technical report,
see: Qualitynet.org > Ambulatory Surgical Centers > Measures > Urology Measure Dry Run > Measure
Methodology.
Risk Adjustment:
The measure’s approach to risk adjustment is tailored to, and appropriate for, a publicly reported outcome
measure as articulated in published scientific guidelines (Krumholz et al., 2006; Normand et al., 2007).
The measure uses a two-level hierarchical logistic regression model to estimate facility-level riskstandardized hospital visit rates. This approach accounts for the clustering of patients within facilities and
variation in sample size across facilities.
The measure adjusts for differences across facilities in patient demographics, clinical factors, and surgeryrelated risk. Potential candidate risk factors were identified from related quality measures and the literature; a
preliminary list of risk factors was developed and then revised based on a Technical Expert Panel (TEP) and
expert clinical input.
The risk-adjustment model has 7 patient-level variables (age and 6 comorbidity variables), number of
qualifying procedures, and work relative value units (RVU) to adjust for surgical complexity (see Table 1).
With the exception of benign prostatic hyperplasia with obstruction which we define using an individual
ICD-9-CM or ICD-10-CM diagnosis code, we define comorbidity variables using CMS Condition
Categories (CCs), which are clinically meaningful groupings of many thousands of ICD-9-CM and ICD-10CM diagnosis codes.
Table 1: Patient-Level Risk-Adjustment Variables
Patient-level variables

Risk-adjusted variables

Demographics

Age (years greater than 65)

Comorbidities

Benign prostatic hyperplasia with obstruction
Complications of specified implanted device or graft
Poisonings and inflammatory allergic reactions
Major symptoms, abnormalities
Parkinson's and Huntington's diseases; seizure disorders and convulsions
Ischemic heart disease

Full details of the development of the risk standardization model for this measure are available at:
Qualitynet.org > Ambulatory Surgical Centers > Measures > Urology Measure Dry Run > Measure
Methodology.
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Data Collection Approach: Medicare administrative claims and enrollment data
Data Accuracy: The administrative claims data used to calculate the measure are maintained by CMS’
Office of Information Services. These data undergo additional quality assurance checks during measure
development and maintenance.
Measure Analysis Suggestions: None
Sampling: No
Data Reported As: ASC-level 7-day risk-standardized, all-cause, unplanned hospital visit rate following
urology surgery
Measure Calculation:
The measure estimates facility-level 7-day risk-standardized unplanned hospital visit rates using hierarchical
logistic regression modeling (a form of hierarchical generalized linear modeling [HGLM]). In brief, the
approach simultaneously models two levels (patient and facility) to account for the variance in patient
outcomes within and between facilities. At the patient level, the model adjusts the log-odds of a hospital visit
within 7 days of the surgery for age, procedural factors, and selected clinical covariates. At the facility level,
it estimates the facility-specific intercepts as arising from a normal distribution. The facility intercept
represents the underlying risk of a hospital visit within 7 days after a urology surgery at an ASC while
accounting for patient risk. The facility-specific intercepts also account for the clustering (non-independence)
of patients within the same facility. If there were no differences among facilities, then after adjusting for
patient risk the facility-specific intercepts would be identical across all facilities. The statistical modeling
approach is described fully in the original technical report:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/Measure-Methodology.html.
Selected References:
1. Cullen KA, Hall MJ, Golosinskiy A, National Center for Health Statistics. Ambulatory surgery in the
United States, 2006. US Department of Health and Human Services, Centers for Disease Control and
Prevention, National Center for Health Statistics; 2009.
2. Krumholz HM, Brindis RG, Brush JE, et al. Standards for statistical models used for public reporting
of health outcomes An American Heart Association scientific statement from the Quality of Care and
Outcomes Research Interdisciplinary Writing Group: Cosponsored by the Council on Epidemiology
and Prevention and the Stroke Council endorsed by the American College of Cardiology Foundation.
Circulation. 2006;113(3):456-462.
3. Normand S-LT, Shahian DM. Statistical and clinical aspects of hospital outcomes profiling.
Statistical Science. 2007;22(2):206-226.

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

Sampling Specifications
ASC-9, ASC-11*, and ASC-13 − The sampling size specifications for ASC-9, ASC-11*, and ASC-13
have been established and are specified in the table below.
Table 3: Sample size requirements per year per ASC for Endoscopy/Polyp Surveillance
(ASC-9) or Cataracts (ASC-11*) measures, or Normothermia Outcome (ASC-13).**
Population Per Year

0-900

Yearly Sample Size

63

Quarterly Sample Size

16

Monthly Sample Size

6

Population Per Year

≥ 901

Yearly Sample Size

96

Quarterly Sample Size

24

Monthly Sample Size
8
*Submission of data for ASC-11 is voluntary.
**For ASCs with fewer than 63 cases, the total population of cases is required.

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[Material inside brac kets ([and]) is new to this Specification s Manual version.]

Quality Data Transmission
Introduction
This section of the manual is provided to highlight the unique data transmission specifications for the
Ambulatory Surgical Center measure data for the Centers for Medicare & Medicaid Services (CMS) and the
CMS Clinical Data Warehouse.
Guidelines for Submission of Data
Data collected for CMS are transmitted to the CMS Clinical Data Warehouse. All data submitted are
required to meet transmission requirements. The file layout requirements are included in this section.
Ambulatory Surgical Center Web-Based Measure Batch Submission File Layout
The Comma-Separated Value (CSV) file layout is one section of content with rows defining unique facilities
and columns defining measure data. Please refer to the Ambulatory Surgical Center Web-Based Batch
Submission file layout for an example and details of required fields.
ASC_PROVIDER_NPI – National Provider ID
ASC_PYR – Payment Year
ASC_9_POP_SIZE – What was your facility’s Total population?
ASC_9_SAMP_SIZE – What was your facility’s sample size?
ASC_9_SAMP_FREQ – What was your facility’s sampling frequency?
ASC_9_NUMERATOR – Patients who have a recommended follow-up interval of at least 10 years
for repeat colonoscopy documented in their colonoscopy report.
ASC_9_DENOMINATOR – All patients aged 50 years and older receiving screening colonoscopy
without biopsy or polypectomy.
ASC_11_POP_SIZE – What was your facility’s Total Population?
ASC_11_SAMP_SIZE – What was your facility’s sample size?
ASC_11_SAMP_FREQ – What was your facility’s sampling frequency?
ASC_11_NUMERATOR – Patients who had an improvement in visual function achieved within 90
days following cataract surgery, based on completing both a pre-operative and post-operative visual
function instrument.
ASC_11_DENOMINATOR – All patients 18 years and older who had cataract surgery and
completed both a pre-operative and post-operative visual function instrument.
ASC_13_POP_SIZE – What was your facility’s Total Population?
ASC_13_SAMP_SIZE – What was your facility’s sample size?
ASC_13_SAMP_FREQ – What was your facility’s sampling frequency?
ASC_13_NUMERATOR – Surgery patients with a body temperature equal to or greater than 96.8
Fahrenheit/36 Celsius recorded within fifteen minutes of Arrival in PACU.

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ASC_13_DENOMINATOR – All patients, regardless of age, undergoing surgical procedures under
general or neuraxial anesthesia of greater than or equal to 60 minutes duration.
ASC_14_NUMERATOR – All cataract surgery patients who had an unplanned anterior vitrectomy.
ASC_14_DENOMINATOR – All cataract surgery patients.
Data Upload Process
Data upload is done through the QualityNet External Files Online Tool.
All data transmitted pass through the following process:
1. The file(s) are checked for proper naming convention and file type.
• The correct file naming convention is ASC_WBM_PY20YY_mm_dd_yyyy.csv where YY
represent the last two digits of the applicable Payment Year, and mm_dd_yyyy represents the
upload date.
2. The file(s) are evaluated upon successful upload and checked for errors in content.
a. The system sends an upload confirmation email to the registered email for the logged-in
account.
b. The system checks the file for errors, logging each error in the file, and then rejects the file if
any errors are found. The error log is attached to the rejection notification email with one
error per line.
c. If no errors are found, the system uploads the file and applies the data to the given Payment
Year.
3. Note that there is no ADD, UPDATE, or DELETE action-code associated with the file. To correct
errors, you can either:
•
•

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

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[Material inside brac kets ([a nd]) is new to t his Specificatio ns Ma nual version.]

Appendix A: Tools and Resources
Alphabetical Tools and Resources List
Measure Name

Page #

ASC-9 : Appropriate Follow-up Interval for Normal Colonoscopy in Average
Risk Patients-Algorithm

A-29

ASC-9: Appropriate Follow-up Interval for Normal Colonoscopy in Average
Risk Patients-Data Collection Tool

A-30

ASC-9: Appropriate Follow-up Interval for Normal Colonoscopy in Average
Risk Patients-Denominator Codes

A-31

ASC-9: Appropriate Follow-up Interval for Normal Colonoscopy in Average
Risk Patients-Fact Sheet

A-32

ASC-11: Improvement in Patient’s Visual Function within 90 Days Following
Cataract Surgery-Data Collection Log

A-33

ASC-13: Normothermia Outcome-Algorithm

A-34

ASC-13: Normothermia Outcome-Example Questions

A-35

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Appendix A-28

ASC-9: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
Numerator Statement: Patients who had a recommended follow-up interval of at least 10 years for repeat
colonoscopy documented in their colonoscopy report
Denominator Statement: All patients ≥ 50 to ≤ 75 years of age receiving screening colonoscopy without biopsy or
polypectomy

Start

Colonoscopy screening performed

N

Documentation of medical
reason(s) for not
recommending at least a
10-year follow-up interval
(e.g., above average risk
patient or inadequate prep)

Patient aged ≥ 50
to ≤ 75 years

Y

Y
Documentation of a
recommended
follow-up interval
of at least 10 years
for repeat
colonoscopy
documented in the
colonoscopy report

Follow-up
interval
of at least
10 years

Biopsy or
polypectomy
performed

N

Y

N

N

Follow-up
interval
of at least
10 years

Exclude from
the
numerator

Exclude from
the
measure
population

Include in the
denominator
population

End

Y

Exclude from
the
measure
population

Include in the
numerator
population

Adapted from algorithm provided by
clinical services group/HCA; January 2019

For use with encounter dates 010120-123120;
Specifications Manual version 9.0
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[Material inside brac kets ([a nd]) is new to t his Specificatio ns Ma nual version.]

ASC-9: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk
Patients-Data Collection Tool
Answer the questions in the tables below to determine whether colonoscopy patients fall into the measures
indicated, keeping in mind that ASC-9 looks forward to recommendations for future care.
ASC- 9
ASC-9: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients
Circle
Denominator/Numerator
Measure Criteria
One
Determination
1. Patient had a screening colonoscopy, without biopsy
Yes
Include in denominator population,
or polypectomy, and is ≥ 50 to ≤ 75 years of age on
continue to 1(a)
date of encounter
No
Exclude from denominator
population
a) Documentation of medical reason(s) for not
Yes
Exclude from denominator
recommending at least a 10-year follow-up
population
interval (e.g., above average risk patient or
inadequate prep or if age is documented as a
No
Continue to Question 2
medical reason)
2. Recommended follow-up interval of at least 10 years
Yes
Include in numerator population
for repeat colonoscopy is documented in colonoscopy
report
No
Exclude from numerator population

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[Material inside brac kets ([a nd]) is new to t his Specificatio ns Ma nual version.]

ASC-9: APPROPRIATE FOLLOW-UP INTERVAL FOR NORMAL COLONOSCOPY
IN AVERAGE RISK PATIENTS-DENOMINATOR CODES
•

For ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal
Colonoscopy in Average Risk Patients, the codes appropriate for use for the denominator are
listed below.

•

These codes are derived from the measure information form for ASC-9 that can be found in
the Specifications Manual, Version 9.0, posted on QualityNet at www.qualitynet.org.

•

Denominator Criteria:
Patients aged ≥ 50 and ≤ 75 on date of encounter
and
Z12.11: Encounter for screening for malignant neoplasm of colon
and
44388: Colonoscopy through Stoma
45378: Diagnostic/screening colonoscopy for non-Medicare patients
G0121: Screening colonoscopy for other Medicare patients
without
Modifier 52: Reduced Services–Under certain circumstances a service or procedure is
partially reduced or eliminated at the physician’s discretion
Modifier 53: Discontinued Procedure–Under certain circumstances the physician may elect
to terminate a surgical or diagnostic procedure
Modifier 73: Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC)
Procedure Prior to the Administration of Anesthesia–Due to extenuating circumstances or
those that threaten the well-being of the patient
Modifier 74: Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC)
Procedure After Administration of Anesthesia–Due to extenuating circumstances or those
that threaten the well-being of the patient
without
Z83.71: Family history of colonic polyps
Z86.010: Personal history of colonic polyps
Z80.0: Family history of malignant neoplasm of gastrointestinal tract
Z85.038: Personal history of malignant neoplasm of large intestine

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[Material inside brac kets ([a nd]) is new to t his Specificatio ns Ma nual version.]

FACT SHEET FOR ASC-9: ENDOSCOPY/POLYP SURVEILLANCE: APPROPRIATE
FOLLOW-UP INTERVAL FOR NORMAL COLONOSCOPY IN AVERAGE RISK PATIENTS
Description: Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy
without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for
repeat colonoscopy documented in their colonoscopy report.
Denominator Statement: All patients aged 50 to 75 years of age receiving screening colonoscopy
without biopsy or polypectomy
Numerator Statement: Patients who had a recommended follow-up interval of at least 10 years for
repeat colonoscopy documented in their colonoscopy report
When abstracting for this measure:
•

Do use the final colonoscopy report to abstract the recommended follow-up interval. If your
facility utilizes another report that is equivalent to or contains the final colonoscopy report, utilize
this report for abstraction.

•

Do exclude a case based on age if there is documentation indicating no follow-up colonoscopy is
needed or recommended and patient's age is identified as the reason.

•

Do use any medical reason, such as a diagnosis, symptom, or condition that is documented in the
medical record to exclude a case from the denominator population only when the recommended
follow-up interval is less than 10 years. Please note that you must have both an interval of less than
10 years and the medical reason documented in order to use this as an exclusion from the
denominator. Some examples are:
o
o
o
o

Above average risk patient
Inadequate prep
Family history of colon cancer
Diverticulitis documented in the medical record

*Please remember that medical reasons are at the discretion of the physician.
•

Do not include records with CPT/HCPCS modifiers 52, 53, 73, or 74.

•

Do not use time frames, such as “5–10 years,” “many,” “prn,” or “when symptomatic,” since they
are not acceptable terms for the recommended follow-up interval of at least 10 years.

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[Material insi de bra ckets ([and]) is ne w to thi s Spe cifications Ma nual v ersion.]

ASC-11: Improvement in Patient’s Visual Function within 90 Days Following
Cataract Surgery-Data Collection Log
When collecting data for ASC-11 (Cataracts – Improvement in Patient’s Visual Function within 90 Days
Following Cataract Surgery):
•

A facility may choose to sample data monthly, quarterly, or annually following the sampling
guidelines in the Specifications Manual.

•

ASC-11 requires that patients complete both a pre- and post-operative survey using the same
visual function tool. Patients who do not complete a pre-op survey and post-op survey are
excluded from the measure. Surveys may be completed in person, by mail, by phone, or another
method of the hospital’s choosing.

•

The data collection instrument is specified as an assessment tool that has been appropriately
validated for the population for which it is being used. The survey tool measures visual function,
not visual acuity. A visual assessment tool may not be utilized. Examples of tools for visual
function assessment are found in the Measure Information Form in the Specifications Manual
under the Definition for Survey.

•

You are not required to use the Data Collection Log, but if you choose to use it, you may modify
it for your facility. You may require fewer columns or fewer rows to accommodate the number
of physicians from whom you need to gather data, or you may add columns to track other helpful
data, such as the total number of surgeries performed at your facility per provider.

•

Consider using the tool as a master log and delete rows to use as a spreadsheet for sending to
individual providers for their input.

•

Designate a sheet for data collection for each month, quarter, or year, and indicate the sample
frequency on the log.

•

Remember that since no specific patient-level data are collected, there are no HIPAA issues
involved with emailing the spreadsheet.

•

At this time, ASC-11 remains a voluntary measure. Facilities that choose not to report the
measure will not be subject to a reduction in their payment update.

•

Any data submitted for the measure will be publicly reported.

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ASC-13: Normothermia
Numerator Statement: Surgery patients with a body temperature equal to or greater than 96.8 Fahrenheit/36 Celsius
recorded within fifteen minutes of arrival in PACU

Denominator Statement: All patients, regardless of age, undergoing surgical procedures under general or neuraxial
anesthesia of greater than or equal to 60 minutes duration

Any patient who had a surgical procedure
performed under general anesthesia or
neuraxial anesthesia

Start

Time
from Start
of anesthesia to End of
anesthesia
Minutes

Exclude from the
measure
population

N

Y
Include in the denominator population

Patient s body
temperature recorded
within 15 minutes
of PACU arrival

Exclude from the
measure
population

N

Y

Enter as Numerator

Y

Recorded
body temperature 96.8°
Fahrenheit or
36° Celsius

N

Exclude from the
measure
population

Y

Physician/APN/PA
document intentional hypothermia
for the procedure performed

N

Do not include in
Numerator

End

Adapted from algorithm provided by
clinical services group/HCA; January 2019

For use with encounter dates 010120-123120;
Specifications Manual version 9.0
A-34

ASC-13: Normothermia Outcome-Example Questions
Step 1: Identify surgical patients with general or neuraxial (epidural or spinal) anesthesia equal
to or greater than 60 minutes in duration (Denominator)
•
•

•

Did the patient have a general or neuraxial anesthetic?
o Cases with strictly sedation or local anesthesia would not be included
What was the Start time of anesthesia?
o If there is no Start time, do not include patient in the Denominator
o If both Start time and Induction time are documented, use Start time
o If there is no Start time but there is an Induction time, do not include patient in
the Denominator
What is the End time of anesthesia?
o If there is no End time, do NOT include patient in the Denominator
o If there is no End time documented, do NOT include patient in the Denominator

If the duration between Start time and End time is equal to or greater than 60 minutes, the patient
can be included in the Denominator.
Step 2: Determine how many patients in the Denominator population had the required body
temperature within 15 minutes of arriving in the PACU (Numerator)
If the patient had a body temperature greater than or equal to 96.8° F or 36° C 15 minutes after
arrival in the PACU, then the patient can be included in the Numerator.
Step 3: Determine if the number of cases meet the Sampling Specifications
If the population is 0-900, a sample of 63 may be used: If the population is greater than or equal
to 901, a sample of at least 96 should be used. If the population is fewer than 63 cases, the total
population of cases is required.
Example: An ASC performed 903 surgical procedures. The number of procedures exceeds 901
and can be sampled using at least 96 cases.
Scenario 1
Medicare patient has surgical procedure using general anesthesia
Start time of anesthesia was 0615
End time of anesthesia was documented on the operating room (OR) form at 0720
Patient’s arrival to PACU was documented at 0725
Body temperature was 36°C at 0730
Denominator criteria met? Yes
Numerator criteria met? Yes
✓ The patient received general anesthesia for the duration of 65 minutes and had a
documented body temperature of 36°C within 15 minutes of arrival in the PACU. This
patient should be included in this measure.

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Scenario 2
Patient started neuraxial anesthetic (spinal) for a surgical procedure at 1000
End time of anesthesia was documented at 1100
Patient arrived into the PACU at 1105
At 1110 patient’s temperature was documented as 96.5°F
Patient’s temperature was rechecked at 1115 and documented as 97°F
Denominator criteria met? Yes
Numerator criteria met? Yes
✓ The patient received neuraxial anesthesia for 60 minutes and had a documented body
temperature of 97°F within 15 minutes of arrival in the PACU. This patient meets the criteria
for both the numerator and denominator.
Scenario 3
Private pay patient received general anesthesia
Anesthetist documented the start time as 0730
The anesthetist documented the end time as 0825
Patient’s arrival time into PACU was documented as 0832
Patient’s body temperature at 0837 was 97.8°F
Denominator criteria met? No
X The anesthesia duration time is not equal to or greater than 60 minutes; therefore, this
patient should not be included in the measure.
Scenario 4
Medicare patient started epidural in pre-op holding at 0800
Patient entered the operating suite at 0810
Documented End time of anesthesia was 0905
Patient’s body temperature recorded at 0920 was 96.5°F
Nurse Practitioner documented intentional hypothermia for the procedure
Denominator criteria met? No
X The documentation of intentional hypothermia is a Denominator Exclusion and excludes
this case from the population; therefore, this patient should not be included in the measure.
Scenario 5
Patient received general anesthesia for surgical procedure
Anesthetist documented Start time at 1010
No documented End time
Patient’s arrival in the PACU is recorded at 1115
Patient’s body temperature was recorded at 1125 at 97°F
Denominator criteria met? No
X Arrival time at PACU is only used to determine if patient’s body temperature meets the
duration and required temperature for inclusion in the Numerator. Anesthesia End time
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cannot be substituted with Arrival at PACU time; therefore, this patient should not be
included in the measure.

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[Material inside brac kets ([a nd]) is new to t his Specificatio ns Ma nual version.]

Appendix B: Preview Section
The Preview Section provides information on new measures. The information provided in this section should
not be programmed or submitted. The measure(s) identified in this section are not currently collected.
No new measures have been introduced for the CY 2023.

ASCQR Specifications Manual
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Appendix B-38