CMS-10530 ASCQR Supporting Statement B 9-10-21

Supporting Statement - Part B

Submission of Information for the Ambulatory Surgical Center Quality Reporting (ASCQR) Program

Collection of Information Employing Statistical Methods

1. Describe potential respondent universe.

All Medicare-certified ASCs receiving reimbursement under the ASC Payment System with a minimum of 240 paid facility claims annually constitute the potential respondent universe required to participate; approximately 3,957 ASCs. In addition, based on an analysis CY 2020 payment determination data, 689 ASCs that were not required to participate submitted data voluntarily. Therefore, we estimate a total respondent universe of 4,646 ASCs.

2. Describe procedures for collecting information.

Data can be collected from quality data codes entered on Medicare non-institutional claims via the CMS-1500 form, via on-line submission directly to CMS through a secure web portal to the Hospital Quality Reporting (HQR) system, and proposed through the Centers for Disease Control and Prevention (CDC) National Health Safety Network (NHSN).

3. Describe methods to maximize response rates.

To maximize response rates, the ASCQR Program provides payment incentive for meeting participation requirements. ASCs that do not meet program requirements may have a 2.0 percentage point reduction to their full annual increase provided under the revised ASC payment system for a given calendar year. In addition, CMS providesto ASC stakeholders education, technical assistance, and a staffed Help Desk to ASCs.

4. Describe any tests of procedures or methods.

Consistent with other CMS quality reporting programs, the ASCQR Program does not require validation of claims-based measures (beyond standard claims validation activities conducted by CMS Medicare Administrative Contractors, known as MACs) or (Web-based) measures for the ASCQR Program. This information collection does not require the use of statistical methods. However, to reduce burden, facilities may sample using their method of choice to reduce the number of cases for which to submit data.

5. Provide name and telephone number of individuals consulted on statistical aspects.

Anita Bhatia, PhD, MPH Grace Snyder, JD MPH

410-786-7236 410-786-0700