Ambulatory Surgical Center Quality Reporting (ASCQR) Program

Ambulatory Surgical Center Quality Reporting Specifications Manual
Release Notes Version 12.0
Release Notes Completed: May 1, 2022
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 01/01/2023, 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, and
Appendix A.

•

Rationale – Provided for the change being made.

•

Description of Changes – Used to identify the section within the document where the change occurs.
Examples are Definitions, Numerator, and Denominator.

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ASCQR Specifications Manual Version 12.0 Release Notes
The notes in the tables below are organized to follow the Table of Contents in the Specifications Manual.

Program Background and Requirements
Impacts: Program Background and Requirements
Rationale: To align with the Calendar Year (CY) 2022 Ambulatory Surgical Center (ASC) Payment System
Final Rule, including the reinstated measures ASC-1 through ASC-4 and the adopted ASC-20 COVID-19
Vaccination Coverage Among Health Care Personnel (HCP COVID-19 Vaccination).
Description of Change:
Background
Add: In the CY 2022 Ambulatory Surgical Center Payment System Final Rule, ASC-1, -2, -3, and -4 were
reinstated in the ASCQR Program beginning with CY 2025 payment determination. These measures will be
collected and submitted as web-based measure data reported via the Hospital Quality Reporting (HQR) site.
Program Requirements
Add: Program requirements for the ASCQR Program include reporting measure data to the Hospital Quality
Reporting (HQR) and National Healthcare Safety Network (NHSN) sites.
Measures Submitted via a Web-Based Tool
Add: Data for ASC-20 are submitted using the web-based tool located on the NHSN portal of the CDC site
at https://www.cdc.gov/nhsn/.
Add: Data for ASC-20 are submitted via the NHSN tool:
https://auth.cdc.gov/siteminderagent/forms/login.fcc?TYPE=33554433&REALMOID=06-2e4e428f-87684f65-a66d-911e49413d9e&GUID=&SMAUTHREASON=0&METHOD=GET&SMAGENTNAME=-SMVfBllSkkIKR6GkMEZgI2o6e2zk%2fxh2fc%2fe5E0N%2fN98H5LsZWkDhX%2fH618YU%2bV1pFG6Dq
c8o%2buj7a7BOjbw3l3DbOwJLzWlX7IAOrlseiUBdD9DB45IS4xFtcl%2fRbqrug&TARGET=-SMhttps%3a%2f%2fsams%2ecdc%2egov%2f

Measure Information Forms Introduction
Impacts: Web-based Measures
Rationale: To include both required submission sites for Web-based Measure data entry.
Description of Change:
Measure Information Form (MIF) Format
Add to Measures Submitted via a Web-based Tool: Either the Hospital Quality Reporting (HQR) site or
the NHSN site via an online tool available to authorized users.

Measure Information Forms
Impacts: ASC-1: Patient Burn

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ASCQR Specifications Manual Version 12.0 Release Notes
Rationale: In the CY 2022 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory
Surgical Center (ASC) Payment System Final Rule, CMS established that data collection for ASC-1 will
resume beginning with the CY 2023 reporting period/CY 2025 payment determinations and subsequent
years. Data for this measure will be reported in HQR as a Web-based Measure.
Description of Change:
Add: ASC-1 Measure Information Form to the 2023 ASCQR Specifications Manual v12.0.
______________________________________________________________________________________
Impacts: ASC-2: Patient Fall
Rationale: In the CY 2022 Hospital OPPS and ASC Payment System Final Rule, CMS established
that data collection for ASC-2 will resume beginning with the CY 2023 reporting period/CY 2025
payment determinations and subsequent years. Data for this measure will be reported in HQR as a
Web-based Measure.
Description of Change:
Add: ASC-2 Measure Information Form to the 2023 ASC Specifications Manual v12.0.
_______________________________________________________________________________________
Impacts: ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant
Rationale: In the CY 2022 Hospital OPPS and ASC Payment System Final Rule Final Rule, CMS
established that data collection for ASC-3 will resume beginning with the CY 2023 reporting period/CY
2025 payment determinations and subsequent years. Data for this measure will be reported in HQR as a
Web-based Measure.
Description of Change:
Add: ASC-3 Measure Information Form to the 2023 ASCQR Specifications Manual v12.0.
_______________________________________________________________________________________
Impacts: ASC-4: All-Cause Hospital Transfer/Admission
Rationale: In the CY 2022 Hospital OPPS and ASC Payment System Final Rule Final Rule, CMS
established that data collection for ASC-4 will resume beginning with the CY 2023 reporting period/CY
2025 payment determinations and subsequent years. Data for this measure will be reported in HQR as a
Web-based Measure.
Description of Change:
Add: ASC-4 Measure Information Form to the 2023 ASC Specifications Manual v12.0.
_______________________________________________________________________________________
Impacts: ASC-11: Cataracts – Improvement in Patient’s Visual Function within 90 Days Following Cataract
Surgery
Rationale: To include CY 2022 Hospital OPPS and ASC Payment System Final Rule Final Rule for
mandatory reporting in CY 2027 payment determination.

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ASCQR Specifications Manual Version 12.0 Release Notes
Description of Change:
Footnotes
Add: Data submission will be mandatory for CY 2027 payment determination and subsequent years
per the CY 2022 Hospital OPPS and ASC Payment System Final Rule (Vol. 86, pp. 63885–63887).
_______________________________________________________________________________________
Impacts: ASC-13
Rationale: Add additional reference that supports the measure as currently specified.
Description of Change:
References
Add: Ban KA, Minei JP, Laronga C, Harbrecht BG, Jensen EH, Fry DE, Itani KM, Dellinger EP, Ko CY,
Duane TM. American College of Surgeons and Surgical Infection Society: Surgical Site Infection
Guidelines, 2016 Update. J Am Coll Surg. 2017 Jan;224(1):59-74.

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Ambulatory Surgical Center Quality Reporting
Specifications Manual
Version 12.0
Encounter Dates: 01-01-23 (1Q23) through 12-31-23 (4Q23)
OMB #0938-1270 Expiration Date: 07-31-2024
[Material inside brackets ([and]) is new to this Specification s Manual version.]

Table of Contents
Acknowledgement ................................................................................................................................................. ii
Program Background and Requirements.......................................................................................................... iii
Section 1: Measure Information Form Introduction ...................................................................................... 1-1
Measure Information Forms-Web-Based Measures
[

[

[

[

ASC-1: Patient Burn………………………………………………………………………………………….1-2

]

ASC-2: Patient Fall…………………………………………………………………………………………...1-5

]

ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant………………………1-7

]

ASC-4: All-Cause Hospital Transfer/Admission……………………………………………………………..1-9

]

ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy
in Average Risk Patients .............................................................................................................................1-11
ASC-11: Cataracts – Improvement in Patient’s Visual Function within 90 Days Following
Cataract Surgery.............................................................................................................................................. 1-13
ASC-13: Normothermia Outcome .................................................................................................................. 1-20
ASC-14: Unplanned Anterior Vitrectomy ...................................................................................................... 1-23
[

ASC-20: COVID-19 Vaccination Coverage Among Health Care Personnel................................................. 1-39

]

Measure Information Forms-Claims-Based Measures
ASC-12: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient
Colonoscopy Introduction ............................................................................................................................... 1-15
ASC-17: Hospital Visits After Orthopedic Ambulatory Surgical Center Procedures Introduction ............... 1-25
ASC-18: Hospital Visits After Urology Ambulatory Surgical Center Procedures Introduction .................... 1-30
ASC-19: Facility-Level 7-Day Hospital Visits after General Surgery Procedures Performed
at Ambulatory Surgical Centers Introduction ................................................................................................. 1-34
Section 2: Sampling Specifications ................................................................................................................... 2-1
Section 3: Quality Data Transmission ............................................................................................................. 3-1
[

Appendix A: Tools and Resources .................................................................................................................. A-1

]

Appendix B: Preview Section ............................................................................................................................B-1

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Acknowledgement
The Ambulatory Surgical Center Quality Reporting Specifications Manual was developed by the Centers
for Medicare & Medicaid Services (CMS) to provide a uniform set of quality measures for the ambulatory
surgical center (ASC) setting. The primary purpose of these measures is to promote high quality care for
patients receiving services in ASC settings.
No royalty or user fee is required for copying or reprinting this manual, but there are conditions required
for use: 1) The copier or printer must disclose that the Ambulatory Surgical Center Quality Reporting
Specifications Manual is periodically updated, and the copied or reprinted version may not be current, unless
the copier or printer has verified and affirmed the version is current. 2) The copier or printer must disclose
that users participating in the Ambulatory Surgical Center Quality Reporting (ASCQR) Program are required
to update their software and associated documentation based on the published Ambulatory Surgical Center
Quality Reporting Specifications Manual production quality timelines.
Example Acknowledgement: The Ambulatory Surgical Center Quality Reporting Specifications Manual
[Version xx, Month, Year] is periodically updated by the Centers for Medicare & Medicaid Services. Users
of the Ambulatory Surgical Center Quality Reporting Specifications Manual must update their software and
associated documentation based on the published manual production timelines.
CPT® only copyright 2022 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
American Medical Association (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!!
To submit Ambulatory Surgical Center Quality Reporting (ASCQR) Program measures to CMS, files
must meet the specifications found only in this CMS manual. Otherwise, the files will be rejected for
not meeting CMS quality data submission requirements and may not receive the full payment update.

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\

Program Background and Requirements
CMS Quality Initiatives
Background
In November 2001, U.S. Department of 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 from 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 the
quality of care provided in hospitals, nursing homes, home health agencies, and physician offices. These
efforts grew under subsequent Secretaries through support and expansion of activities that strengthen
healthcare transparency and value-driven healthcare.
The Medicare Improvements and Extension Act under Division B of Title I of the Tax Relief and Health
Care Act (MIEA-TRHCA) of 2006 (Pub. L. 109–432), enacted on December 20, 2006, made changes in the
Hospital Outpatient Prospective Payment System (OPPS). In the Calendar Year (CY) 2008 Hospital
Outpatient Prospective Payment and Ambulatory Surgical Center (ASC) Payment Systems Final Rule, the
Centers for Medicare & Medicaid Services (CMS) became statutorily required to have a program under
which ASCs will report data on the quality of their care using standardized measures to receive the full
annual update (APU) 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 (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.
Claims-based 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 ASCQR Program; however, data collection was
suspended beginning with the CY 2021 payment determination until further action in rulemaking, with the
goal of updating the data submission method. In the CY 2022 Ambulatory Surgical Center Payment System
Final Rule, ASC-1, -2, -3, and -4 were reinstated in the ASCQR Program beginning with CY 2025 payment
determination. These measures will be collected and submitted as web-based measure data reported via the
Hospital Quality Reporting (HQR) site.
[

]

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 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
[

Program requirements for the ASCQR Program include reporting measure data to the HQR and National
Healthcare Safety Network (NHSN) sites. ASCs that do not meet program requirements may receive a twopercent point 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, located on the Regulations page of CMS.gov (https://www.cms.gov/Regulations).
]

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, 2021, with claim submission on January 1, 2022, this claim would be included in the CY
2023 payment determination.
Measures Submitted via a Web-Based Tool
Data for ASC-1, ASC-2, ASC-3, ASC-4, ASC-9, ASC-11 (a voluntary measure), ASC-13, and ASC-14 are
to be submitted using a web-based tool located on HQR at https://hqr.cms.gov/.
Data for ASC-20 are submitted using the web-based tool located on the NHSN portal of the Centers for
Disease Control and Prevention (CDC) site at https://www.cdc.gov/nhsn/.
Annual Data Submission Period: See the timeline posted to the ASCQR Program page of QualityNet
(https://qualitynet.cms.gov/asc/ascqr) for these measures.
Submission Instructions: Data entry achieved through the HQR site via an online tool is available to
authorized users. After logging into the site:
•
•
•
•
•
•
•

Select Data Submission from the left side screen Lock Menu.
Select Data Form.
Select Launch Data Form to open the submission application.
Select Start Measures to enter data.
Enter data for a measure and then select the Save and Return icon. Repeat this process for
each required measure until all required data is complete.
Facilities that do not have data for a required measure should select the checkbox marked,
“Please enter zeros for this measure, as I have no data to submit.”
Select “I’m ready to submit” dial at the bottom of the page. The All Measures Successfully
Submitted screen will display, and the data submission process is complete.
o The dial will remain grayed out until all required measures are completed.
The dial will turn blue when all required measures are completed.
o Data are not recognized as officially submitted until the I’m ready to submit icon is
selected and the All Measures Successfully Submitted screen displays.

The File Upload option requires the approved CSV template to be used. File upload may be used by vendors
or corporations submitting data for more than one ASC at the same time.

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Data for ASC-20 are submitted via the NHSN tool at:
https://auth.cdc.gov/siteminderagent/forms/login.fcc?TYPE=33554433&REALMOID=06-2e4e428f-87684f65-a66d-911e49413d9e&GUID=&SMAUTHREASON=0&METHOD=GET&SMAGENTNAME=-SMVfBllSkkIKR6GkMEZgI2o6e2zk%2fxh2fc%2fe5E0N%2fN98H5LsZWkDhX%2fH618YU%2bV1pFG6Dq
c8o%2buj7a7BOjbw3l3DbOwJLzWlX7IAOrlseiUBdD9DB45IS4xFtcl%2fRbqrug&TARGET=-SMhttps%3a%2f%2fsams%2ecdc%2egov%2f
[

]

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
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 HHS Secretary must establish procedures to make data collected under the ASCQR 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 (i.e., the Extraordinary Circumstance Exception
request process) and the reconsideration request process were finalized in the FY 2013 Inpatient Prospective
Payment System (IPPS)/Long-Term Care Hospital Prospective Payment System (LTCH PPS) 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 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 MIFs.
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 Office of Management and Budget (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: 07-31-2024
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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 (e.g., 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 either the Hospital
Quality Reporting (HQR) site or the National Healthcare Safety Network (NHSN) site 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: Patient Burn
Measure ID #: ASC-1
Quality Reporting Option: Measures Submitted via a Web-based Tool
Description: The number of admissions (patients) who experience a burn prior to discharge
from the ASC
Numerator: ASC admissions experiencing a burn prior to discharge
Denominator: All ASC admissions
Numerator Inclusions: ASC admissions experiencing a burn prior to discharge
Numerator Exclusions: None
Denominator Inclusions: All ASC admissions
Denominator Exclusions: None
Definitions:
•

Admission – Completion of registration upon entry into the facility

•

Burn – Unintended tissue injury caused by any of the six recognized mechanisms: scalds,
contact, fire, chemical, electrical, or radiation (e.g., warming devices, prep solutions,
electrosurgical unit, or laser)

•

Discharge – Occurs when the patient leaves the confines of the ASC

Selection Basis:
There are numerous case reports in the literature regarding patient burns in the surgical and
procedural setting. The diversity of the causative agents underscores the multitude of potential
risks that must be properly mitigated to avoid patient burns.
The literature on burns suggests that electrosurgical burns are most common. A recent
publication from the ECRI Institute (www.ecri.org) highlights the increased risk of burns with
newer surgical devices that apply higher currents at longer activation times. Although electrical
burns are most prevalent, other mechanisms of burn injury are frequently reported in case studies
and case series. These include chemical and thermal burns.
Surgical fires are rare; however, their consequences can be grave, killing or seriously injuring
patients and surgical staff. The risk of surgical fire is present whenever and wherever surgery is
performed, whether in an operating room (OR), a physician’s office, or an outpatient clinic.
Recognizing the diversity of mechanisms by which a patient could sustain an unintentional burn
in the ASC setting, the definition of burn is broad, encompassing all six recognized means by
which a burn can occur – scalds, contact, fire, chemical, electrical, or radiation. This will allow
stakeholders to develop a better understanding of the incidence of these events and further refine
means to ensure prevention.

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Clinical Recommendation Statements:
The risk of burns related to laser use can be reduced by adherence to the guidelines published by
the American National Standards Institute (ANSI) for safe use of these devices in the health care
setting. Similarly, the risk of burns related to the use of electrosurgical devices can be reduced by
following the electrosurgery checklist published by ECRI Institute.
The risk of surgical fires can be reduced by minimizing ignition, oxidizer, and fuel risks (the
“classic triangle”). The American Society of Anesthesiologist’s Practice Advisory for the
Prevention and Management of Operating Room Fires seeks to prevent the occurrence of OR
fires, reduce adverse outcomes associated with OR fires, and identify the elements of a fire
response protocol. These guidelines are available at https://asahq.org/standards-and-guidelines.
Guidance for the prevention of surgical fire has also been published by the Association of
Perioperative Registered Nurses (AORN).
Additional information and resources, such as sample data collection forms and frequently asked
questions (FAQs) about the measures, can be found on the ASC Quality Collaboration website at
www.ascquality.org.
Annual Data Submission Period:
See the timeline posted to QualityNet.CMS.gov for this measure. Select Ambulatory Surgical
Centers. Then, select Data Submission from the banner options. Click the Deadlines tile from the
left side of the page. Data will be completed through the Hospital Quality Reporting (HQR)
Secure Portal at https://hqr.cms.gov via an online tool available to authorized users.
Selected References:
•
•
•
•
•
•
•
•
•

American National Standards Institute (ANSI) Z136.3 (2018) – Safe Use of Lasers in
Health Care Facilities, 2018 Revision.
Apfelbaum JL, et al. Practice advisory for the prevention and management of operating
room fires: an updated report by the American Society of Anesthesiologists Task Force on
Operating Room Fires. Anesthesiology. 2013 Feb;118(2):271-90.
Anesthesia Patient Safety Foundation (APSF). Prevention and management of surgical
fires video. February 2010. http://www.apsf.org/resources_video.php.
ECRI Institute. Surgical Fires. June 1, 2016.
ECRI Institute. Electrosurgery Checklist. 2020.
National Fire Protection Association (NFPA). NFPA 99: Health Care Facilities Code.
Quincy, MA: NFPA, 2018.
ECRI Institute. Continued use of "flying lead" bipolar electrosurgical cables could result
in misconnections and patient burns. Health Devices. 2018 Nov 28.
Jones SB, et al. Fundamental Use of Surgical Energy (FUSE): An Essential Educational
Program for Operating Room Safety. Perm J. 2017;21. pii: 16-050.
Tucker R. Laparoscopic electrosurgical injuries: survey results and their implications.
Surg Laparosc Endosc. 1995;5(4):311-7.

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•
•
•

•

ECRI. Higher currents, greater risks: preventing patient burns at the return-electrode site
during high- current electrosurgical procedures. Health Devices. 2005; 34(8):273-9.
Demir E, O’Dey D, and Pallua N. Accidental burns during surgery. J Burn Care Res.
2006; 27(6):895- 900.
Cheney F, Posner K, Caplan R, and Gild W. Burns from warming devices in anesthesia. A
closed claims analysis. Anesthesiology. 1994; 80(4):806-10.Mehta SP, Bhananker SM,
Posner KL, Domino KB. Operating room fires: a closed claims analysis. Anesthesiology.
2013 May;118(5):1133-9.
Jones EL, et al. Operating Room Fires and Surgical Skin Preparation. J Am Coll Surg.
2017 Jul;225(1):160-165.

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Measure Information Form
Measure Title: Patient Fall
Measure ID #: ASC-2
Quality Reporting Option: Measures Submitted via a Web-based Tool
Description: The number of admissions (patients) who experience a fall within the ASC
Numerator: ASC admissions experiencing a fall within the confines of the ASC
Denominator: All ASC admissions
Numerator Inclusions: ASC admissions experiencing a fall within the confines of the ASC
Numerator Exclusions: ASC admissions experiencing a fall outside the ASC
Denominator Inclusions: All ASC admissions
Denominator Exclusions: None
Definitions:
•

Admission – Completion of registration upon entry into the facility

•

Fall – A sudden, uncontrolled, unintentional, downward displacement of the body to the
ground or other object, excluding falls resulting from violent blows or other purposeful
actions (Source: National Center for Patient Safety)

Selection Basis:
“Falls per 100,000 patient days” has been endorsed as a serious reportable event by the NQF.
While ASCs have a relatively low incidence of adverse events in general, information
regarding the incidence of patient falls is not currently available. However, stakeholders have
expressed a general interest in the public reporting of such adverse events. Due to the use of
anxiolytics, sedatives, and anesthetic agents as adjuncts to procedures, patients undergoing
outpatient surgery are at increased risk for falls.
Clinical Recommendation Statements:
According to the Agency for Healthcare Research and Quality’s Prevention of Falls in Acute
Care guideline, patient falls may be reduced by following a four-step approach: 1) evaluating
and identifying risk factors for falls in the older patient; 2) developing an appropriate plan of
care for prevention; 3) performing a comprehensive evaluation of falls that occur; and 4)
performing a post-fall revision of plan of care as appropriate.
Additional information and resources, such as sample data collection forms and frequently
asked questions (FAQs) about the measures, can be found on the ASC Quality Collaboration
website at www.ascquality.org.

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Annual Data Submission Period:
See the timeline posted to https://QualityNet.CMS.gov for this measure. Select Ambulatory
Surgical Centers. Then, select Data Submission from the banner options. Click the Deadlines
tile from the left side of the page. Data will be submitted through the Hospital Quality
Reporting (HQR) Secure Portal at https://hqr.cms.gov via an online tool available to
authorized users.
Selected References:
•
•
•
•
•
•
•
•

•
•
•
•

LeCuyer M, Lockwood B, Locklin M. Development of a Fall Prevention Program in the
Ambulatory Surgery Setting. J Perianesth Nurs. 2017 Oct;32(5):472-479.
Boushon B, Nielsen G, Quigley P, Rutherford P, Taylor J, Shannon D. Transforming
Care at the Bedside How-to-Guide: Reducing Patient Injuries from Falls. Cambridge,
MA: Institute for Healthcare Improvement; 2008.
ECRI Institute. Fall Injury Prevention Interventions. August 1, 2015.
The Joint Commission. Sentinel Event Alert 55: Preventing falls and fall-related injuries
in health care facilities. September 28, 2015.
VA National Center for Patient Safety: United States Department of Veterans Affairs.
Falls Toolkit. http://www.patientsafety.va.gov/professionals/onthejob/falls.asp. Last
accessed February 15, 2022.
National Quality Forum. Serious Reportable Events in Healthcare 2011 Update. 2011.
Gray-Micelli D. Preventing falls in acute care. In: Capezuti E, Zwicker D, Mezey M,
Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed.
New York (NY): Springer Publishing Company. 2008. P. 161-98.
American Geriatrics Society/British Geriatrics Society Panel on Prevention of Falls in
Older Persons. Summary of the Updated American Geriatrics Society/British Geriatrics
Society Clinical Practice Guideline for Prevention of Falls in Older Persons. Journal of
the American Geriatrics Society, 2011;59(1):148-157.
Amador LF, Loera JA. Preventing Postoperative Falls in the Older Adult. J Am Coll
Surg. 2007 Mar;204(3):447-453.
Resnick, B. (2003). Preventing falls in acute care. In: M. Mezey, T. Fulmer, I. Abraham
(Eds.) & D. Zwicker (Managing Ed.), Geriatric nursing protocols for best practice (2nd
ed., pp. 141-164). New York: Springer Publishing Company, Inc.
University of Iowa Gerontological Nursing Interventions Research Center (UIGN).
(2004). Falls prevention for older adults. Iowa City, IA. University of Iowa
Gerontological Nursing Interventions Research Center, Research Dissemination Core.
Kronzer VL, Wildes TM, Stark SL, Avidan MS. Review of perioperative falls. Br J
Anaesth. 2016 Dec;117(6):720-732.

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Measure Information Form
Measure Title: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant
Measure ID #: ASC-3
Quality Reporting Option: Measures Submitted via a Web-based Tool
Description: The number of admissions (patients) who experience a wrong site, side, patient,
procedure, or implant
Numerator: All ASC admissions experiencing a wrong site, wrong side, wrong patient,
wrong procedure, or wrong implant
Denominator: All ASC admissions
Numerator Inclusions: All ASC admissions experiencing a wrong site, wrong side, wrong
patient, wrong procedure, or wrong implant
Numerator Exclusions: None
Denominator Inclusions: All ASC admissions
Denominator Exclusions: None
Definitions:
•

Admission – Completion of registration upon entry into the facility

•

Wrong – Not in accordance with intended site, side, patient, procedure, or implant

Selection Basis:
“Surgery performed on the wrong body part,” “surgery performed on the wrong patient,” and
“wrong surgical procedure performed on a patient” have all been endorsed as serious
reportable surgical events by NQF. This outcome measure serves as an indirect measure of
providers’ adherence to The Joint Commission’s “Universal Protocol” guideline. The Joint
Commission, an accreditation body, has developed a “Universal Protocol” guideline for
eliminating wrong site, wrong procedure, wrong person surgery. The Universal Protocol is
based on the consensus of experts and is endorsed by more than 40 professional medical
associations and organizations. To encompass the outcomes of all key identification
verifications, the ASC Quality Collaboration’s measure incorporates not only wrong site,
wrong side, wrong patient, and wrong procedure, but also wrong implant in its specifications.
Clinical Recommendation Statements:
The Joint Commission’s “Universal Protocol” is based on the consensus of experts from the
relevant clinical specialties and professional disciplines and is endorsed by more than 40
professional medical associations and organizations.
Additional information and resources, such as sample data collection forms and frequently
asked questions (FAQs) about the measures, can be found on the ASC Quality Collaboration
website at www.ascquality.org.

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Annual Data Submission Period:
See the timeline posted to QualityNet.CMS.gov for this measure. Select Ambulatory Surgical
Centers. Then, select Data Submission from the banner options. Click the Deadlines tile from
the left side of the page. Data will be submitted through the Hospital Quality Reporting (HQR)
Secure Portal at https://hqr.cms.gov via an online tool available to authorized users.
Selected References:
•

•
•
•
•
•
•
•
•

Joint Commission. Universal Protocol For Preventing Wrong Site, Wrong Procedure,
Wrong Person Surgery. Available at
https://www.jointcommission.org/standards/universal-protocol. Last accessed February
15, 2022.
American Academy of Ophthalmology. Recommendations of American Academy of
Ophthalmology Wrong Site Task Force. https://www.aao.org/patient-safetystatement/recommendations-of-american-academy-ophthalmology-. Aug 2014.
American Academy of Orthopaedic Surgeons. Surgical Site and Procedure Confirmation.
Information Statement 1043. March 2015.
American College of Obstetricians and Gynecologists. ACOG committee opinion #464:
patient safety in the surgical environment. Obstet Gynecol. 2010; 116(3):786-790.
American College of Surgeons. Revised Statement on Safe Surgery Checklists, and
Ensuring Correct Patient, Correct Site, and Correct Procedure Surgery. October 1, 2016.
https://www.facs.org/about-acs/statements/93-surgery-checklists.
AORN. AORN Position Statement on Preventing Wrong-Patient, Wrong-Site, WrongProcedure Events. https://www.aorn.org/guidelines/clinical-resources/position-statements.
February 23, 2021.
Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC:
National Academy Press, 2000.
National Quality Forum. Serious Reportable Events in Healthcare – 2011 Update: A
Consensus Report. 2011.
World Health Organization. WHO Guidelines for Safe Surgery 2009.

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Measure Information Form
Measure Title: All-Cause Hospital Transfer/Admission
Measure ID #: ASC-4
Quality Reporting Option: Measures Submitted via a Web-based Tool
Description: The percentage of ASC admissions (patients) who are transferred or admitted to
a hospital upon discharge from the ASC
Numerator: ASC admissions requiring a hospital transfer or hospital admission upon
discharge from the ASC
Denominator: All ASC admissions
Numerator Inclusions: ASC admissions requiring a hospital transfer or hospital admission
upon discharge from the ASC
Numerator Exclusions: None
Denominator Inclusions: All ASC admissions
Denominator Exclusions: None
Definitions:
•

Admission – Completion of registration upon entry into the facility

•

Hospital Transfer/Admission – Any transfer/admission from an ASC directly to an
acute care hospital including hospital emergency room

•

Discharge – Occurs when the patient leaves the confines of the ASC

Selection Basis:
The need for transfer/admission is an unanticipated, but sometimes necessary outcome.
Hospital transfers/admissions can result in unplanned cost and time burdens that must be
borne by patients and payers.
Selected states have expressed an interest in the public reporting of such events. While
hospital transfers and admissions undoubtedly represent good patient care when necessary,
high rates may be an indicator that practice patterns or patient selection guidelines are in need
of review.
Clinical Recommendation Statements:
No clinical practice guidelines specifically addressing transfers or admissions from ASCs to
acute care hospitals are available at this time.
Additional information and resources, such as sample data collection forms and frequently
asked questions (FAQs) about the measures, can be found on the ASC Quality Collaboration
website at www.ascquality.org.

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Annual Data Submission Period:
See the timeline posted to QualityNet.CMS.gov for this measure. Select Ambulatory Surgical
Centers. Then, select Data Submission from the banner options. Click the Deadlines tile from
the left side of the page. Data will be submitted through the Hospital Quality Reporting (HQR)
Secure Portal at https://hqr.cms.gov via an online tool available to authorized users.
Selected References:
•
•
•
•
•
•
•
•
•
•
•

Coley K et al. Retrospective evaluation of unanticipated admissions and readmissions after
same day surgery and associated costs. J. Clin Anesth. 2002; 14:349-353.
Sawhney M et al. Pain and haemorrhage are the most common reasons for emergency
department use and hospital admission in adults following ambulatory surgery: results of a
population-based cohort study. Perioper Med (Lond). 2020 Aug 19;9:25.
Brown CR et al. Unplanned Emergency Visits and Admissions After Orthopaedic
Ambulatory Surgery in the First 2 Years of Operation of a University Ambulatory Surgery
Center. Am J Sports Med. 2021 Feb;49(2):505-511.
Tewfik MA, et al. Factors affecting unanticipated hospital admission following
otolaryngologic day surgery. J Otolaryngol. 2006 Aug; 35(4):235-41.
Mull HJ et al. Factors Associated with Hospital Admission after Outpatient Surgery in the
Veterans Health Administration. Health Serv Res. 2018 Oct;53(5):3855-3880.
Lau H, Brooks DC. Predictive factors for unanticipated admissions after ambulatory
laparoscopic cholecystectomy. Arch Surg. 2001 Oct; 136(10):1150-3.
Junger A, Klasen J, Benson M, Sciuk G, Hartmann B, Sticher J, Hempelmann G. Factors
determining length of stay of surgical day-case patients. Eur J Anaesthesiol. 2001 May;
18(5):314-21.
Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery—a prospective
study. Can J Anaesth. 1998 Jul; 45(7):612-9.
Margovsky A. Unplanned admissions in day-case surgery as a clinical indicator for quality
assurance. Aust N Z J Surg. 2000 Mar; 70(3):216-20.
Lledó JB, Planells M, Espí A, Serralta A, García R, Sanahuja A. Predictive model of
failure of outpatient laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech.
2008 Jun; 18(3):248-53.
Fox JP, Vashi AA, Ross JS, Gross CP. Hospital-based, acute care after ambulatory surgery
center discharge. Surgery. 2014 May;155(5):743-53.

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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 Exclusion:
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.

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Annual Data Submission Period: See the timeline posted to QualityNet.CMS.gov for this measure. Select
Ambulatory Surgical Centers, then select Data Submission from the banner options. Click the Deadlines tile
from the left side of the page. Data will be completed through the Hospital Quality Reporting (HQR) site at
https://hqr.cms.gov via an online tool available to authorized users.
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 pre-operative
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 (without modifiers 55 or 56): 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984,
66987, 66988
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.CMS.gov for this measure. Select
Ambulatory Surgical Centers, then select Data Submission from the banner options. Click the Deadlines tile
from the left side of the page. Data will be completed through the Hospital Quality Reporting (HQR) site at
https://hqr.cms.gov 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 Institute Visual
Function Questionnaire (NEI-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 non-missing
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). Data submission will be mandatory for CY 2027
payment determination and subsequent years per the CY 2022 OPPS/ASC Final Rule (Vol. 86, pp.
63885–63887).
[

]

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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 claimbased 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 2025. Beginning with payment determination year 2020, CMS
began calculating the measure with three years of claims data. For payment determination year 2025, the
performance period is January 2021 through December 2023.
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
(https://qualitynet.cms.gov/asc/measures/colonoscopy/methodology).
CMS provides a new report each year to align with the most current calendar year. For example, the 2018
Measure Updates and Specifications Report aligned 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:
https://cmsqualitysupport.servicenowservices.com/qnet_qa
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
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 risk- standardized, 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 up to 12 months prior to the date of procedure to ensure the availability 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: https://qualitynet.cms.gov/asc/measures/colonoscopy/methodology (In prior years, all
measure codes are located within the Measure Updates and Specifications Reports.)

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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
(https://qualitynet.cms.gov/asc/measures/colonoscopy/methodology). 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:
https://qualitynet.cms.gov/asc/measures/colonoscopy/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 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 Variables
Risk-Adjusted Variables
Demographics
Age (categorized; 65–69; 70–74; 75–79; 80–84; 85+)
Endoscopy during Procedure
Procedural Factors
Polypectomy during Procedure
Congestive Heart Failure
Ischemic Heart Disease
Stroke/Transient Ischemic Attack (TIA)
Chronic Lung Disease
Metastatic Cancer
Liver Disease
Comorbidities
Iron Deficiency Anemia
Disorders of Fluid, Electrolyte, Acid Base
Pneumonia
Psychiatric Disorders
Substance Abuse
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.
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.

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The facility-specific 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 (non- independence) of patients within the same facility. If there were no differences
among facilities, the facility- specific 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
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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Measure Information Form
Measure Title: Normothermia Outcome
Measure ID #: ASC-13
Quality Reporting Option: Measures 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 who 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/advance practice nurse/physician’s assistant
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 (post-anesthesia care unit)*.
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.
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 postanesthetic 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.
* 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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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 patients having surgical
procedures under general or neuraxial anesthesia of 60 minutes or more in duration who are normothermic
within 15 minutes of arrival in PACU?
Annual data submission period: See the timeline posted to QualityNet.CMS.gov for this measure; select
Ambulatory Surgical Centers then Data Submission from the banner options, then click the Deadlines tile
from the left side of the page. Data will be submitted through the Hospital Quality Reporting (HQR) Secure
Portal at https://hqr.cms.gov via an online tool available to authorized users.
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.
Ban KA, Minei JP, Laronga C, Harbrecht BG, Jensen EH, Fry DE, Itani KM, Dellinger EP, Ko CY,
Duane TM. American College of Surgeons and Surgical Infection Society: Surgical site infection
guidelines, 2016 update. J Am Coll Surg. 2017 Jan;224(1):59–74.
[

]

Balki I et al. Effect of perioperative active body surface warming systems on analgesic and clinical
outcomes: a systematic review and meta-analysis of randomized controlled trials. Anesth Analg. 2020
Nov;131(5):1430-1443.
Berrios-Torres SI et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical
Site Infection, 2017. JAMA Surg. 2017 Aug 1;152(8):784–791.
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):95–97.
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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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 surgery patients who have an
unplanned anterior vitrectomy.
Numerator: All cataract surgery patients who had an unplanned anterior vitrectomy.
Denominator: All cataract surgery patients.
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: See the timeline posted to QualityNet.CMS.gov for this measure. Select
Ambulatory Surgical Centers, then select Data Submission from the banner options. Click the Deadlines tile
from the left side of the page. Data will be completed through the Hospital Quality Reporting (HQR) site at
https://hqr.cms.gov via an online tool available to authorized users.
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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Centers for Medicare & Medicaid Services (CMS)
Risk-Standardized Hospital Visits within 7 Days after Orthopedic
Ambulatory Surgical Center (ASC) Procedures Measure
Introduction
This section of the manual includes the Measure Information Form (MIF) for the RiskStandardized 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 (YNHHSC/CORE) developed the measure for the 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’ 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 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-PatientAssessment- Instruments/HospitalQualityInits/Measure-Methodology.html).
Please submit questions about the measure to the QualityNet Question and Answer Tool:
https://cmsqualitysupport.servicenowservices.com/qnet_qa

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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 up
to 12 months prior to the date of surgery to ensure the availability of data for identifying
comorbidities for risk adjustment.
The measure includes procedures that are routinely performed at ASCs, involve increased risk
of post- surgery hospital visits, and are routinely performed by orthopedists. For a list of
procedure codes included in the measure cohort, see: https://qualitynet.cms.gov > Ambulatory
Surgical Centers > Measures > Orthopedic Measure > Methodology.

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Exclusion:
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.
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 https://qualitynet.cms.gov > Ambulatory
Surgical Centers > Measures > Orthopedic 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-10-CM diagnosis
code, we define comorbidity variables using
CMS Condition Categories (CCs), which are clinically meaningful groupings of
many thousands of ICD-10-CM diagnosis codes.

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Table 1: Patient-Level Risk-Adjustment Variables
Patient-Level Variables
Risk-Adjusted Variables
Demographics
Age (years greater than 65)
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
Vascular disease
Comorbidities
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
Surgical Procedural
Complexity

Work RVU

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Full details of the development of the risk standardization model for this measure are available at
https://qualitynet.cms.gov > Ambulatory Surgical Centers > Measures > Orthopedic 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.
Selected References:
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.
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. Statistical
Science. 2007;22(2):206–226.

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Medicare & Medicaid Services (CMS) Risk Standardized Hospital Visits within 7 Days after Urology
Ambulatory Surgical Center (ASC) Procedures Measure
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 (YNHHSC/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’ 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 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-Assessment-Instruments/Hospital
QualityInits/Measure-Methodology.html). Please submit questions about the measure to the QualityNet
Question and Answer Tool: https://cmsqualitysupport.servicenowservices.com/qnet_qa.

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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 up to 12 months prior to the date
of surgery to ensure the availability of data for identifying comorbidities 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: https://qualitynet.cms.gov/ > Ambulatory Surgical Centers > Measures > Urology
Measure > Methodology.
Exclusion:
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:
https://qualitynet.cms.gov/ > Ambulatory Surgical Centers > Measures > Urology 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 ICD10-CM diagnosis code, we define comorbidity variables using CMS Condition Categories (CCs), which are
clinically meaningful groupings of many thousands of ICD-10-CM diagnosis codes.
Table 1: Patient-Level Risk-Adjustment Variables
Patient-Level Variables
Risk-Adjusted Variables
Demographics
Age (years greater than 65)
Benign prostatic hyperplasia with obstruction
Complications of specified implanted device or graft
Poisonings and inflammatory allergic reactions
Comorbidities
Major symptoms, abnormalities
Parkinson's and Huntington's diseases; seizure disorders and convulsions
Ischemic heart disease
Number of Qualifying
Defined as 2 vs. 1, 3, or more vs. 1
Procedures
Surgical Procedural
Work RVU
Complexity
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Full details of the development of the risk standardization model for this measure are available at:
https://qualitynet.cms.gov/ > Ambulatory Surgical Centers > Measures > Urology 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
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/QualityInitiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology.html.
Selected References:
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.
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. Statistical
Science. 2007;22(2):206–226.

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Centers for Medicare & Medicaid Services (CMS)
General Surgery Ambulatory Surgical Center Procedures Measure
Introduction
This section of the manual includes the Measure Information Form (MIF) for the Facility-Level7-Day Hospital Visits after General Surgery Procedures Performed at Ambulatory Surgical
Centers (ASC) 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’ 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 general 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 2024.
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-InitiativesPatient-Assessment-Instruments/Hospital QualityInits/Measure-Methodology.html). Please
submit questions about the measure to the QualityNet Question and Answer Tool:
https://cmsqualitysupport.servicenowservices.com/qnet_qa

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Measure Information Form
Performance Measure Name: Facility-Level-7-Day Hospital Visits after General
Surgery Procedures
Measure ID #: ASC-19
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 general surgery at an ASC among Medicare fee-forservice (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 general 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 general
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 general surgeries, typically performed by a general surgeon, at ASCs.
Included Populations:
The target population is Medicare FFS patients aged 65 years and older undergoing outpatient
general 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 general surgeons. For a list of
procedure codes included in the measure cohort, see: https://qualitynet.cms.gov/ > Ambulatory
Surgical Centers > Measures > General Surgery Measure Dry Run > Measure Methodology

Exclusion:
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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.
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 (major organ
transplant, rehabilitation, or maintenance chemotherapy);
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: https://qualitynet.cms.gov/ > Ambulatory Surgical Centers >
Measures > General Surgery 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
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 a
Technical Expert Panel (TEP) and expert clinical input.
The risk-adjustment model has 19 patient-level variables (age and 18 comorbidity variables), six
procedure types, and work relative value units (RVU) to adjust for surgical complexity (see Table
1). We define comorbidity variables using CMS Condition Categories (CCs), which are clinically
meaningful groupings of many thousands of ICD-10-CM diagnosis codes.

Table 1: Patient-Level Risk-Adjustment Variables
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Patient-Level Variables
Risk-Adjusted Variables
Demographics
Age (years greater than 65)
Abdomen and its
contents Alimentary
tract
Procedure Type
Breast
Skin/soft
tissue Wound
Other benign tumors
Liver or biliary
disease
Intestinal obstruction or perforation
Dementia or senility
Psychiatric disorders
Other significant central nervous system (CNS)
disease Ischemic heart disease
Specified arrhythmias and other heart rhythm
Comorbidities
disorders Stroke
Chronic lung
disease Pneumonia
Dialysis or sever chronic kidney
disease Benign prostatic hyperplasia
Cellulitis, local skin infection
Major traumatic fracture or internal
injury Complicates of care
Chronic anticoagulant
Surgical Procedural
Work RVU
Complexity
Full details of the development of the risk standardization model for this measure are available at
https://qualitynet.cms.gov/ > Ambulatory Surgical Centers > Measures > General Surgery
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’s 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 general surgery

Measure Calculation: The measure estimates facility-level, 7-day risk-standardized unplanned
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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 general surgery at an ASC 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,
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:
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.
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.
Statistical Science. 2007;22(2):206–226.

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Measure Information Form
Performance Measure Name: COVID-19 Vaccination Coverage Among Health Care Personnel
(HCP COVID-19 Vaccination)
Measure ID #: ASC-20
Measure Set: Measures submitted via a web-based tool (NHSN)
Description: For more information about the National Healthcare Safety Network (NHSN) measures,
see the resources located at http://www.cdc.gov/nhsn/.
Annual data submission period: See the timeline posted to QualityNet.cms.gov for this measure; select
Ambulatory Surgical Centers (ASC) then click the Learn More dial, then select Resources from the banner
options.
Direct questions regarding NHSN training, enrollment, and submission to: [email protected].
Denominator: Number of HCP eligible to work in the ASC for at least 1 day during the self-selected week,
excluding persons with contraindications to COVID-19 vaccination.
Numerator: cumulative number of HCP eligible to work in at the ASC for at least 1 day during the selfselected week and who received a complete vaccination course against COVID-19 using an FDA-authorized
or FDA-approved vaccine for COVID-19 (whether the FDA issued an approval or EUA).160 A complete
vaccination course is defined under the specific FDA authorization and may require multiple doses or
regular revaccination.
FAQs on Reporting COVID-19 Vaccination Data can be found at https://www.cdc.gov/nhsn/hps/weeklycovid-vac/faqs.html.

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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
Yearly Sample Size

0–900
63

Quarterly Sample Size

16

Monthly Sample Size

6

Population Per Year

≥ 901

Yearly Sample Size

96

Quarterly Sample Size

24

Monthly Sample Size
*Submission of data for ASC-11 is voluntary for CY 2023 reporting period.
**For ASCs with fewer than 63 cases, the total population of cases is required.

8

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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 Hospital Quality Reporting Data Form .
[

]

Guidelines for Submission of Data
Data collected for CMS are transmitted to the Hospital Quality Reporting Data Form . 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_1_NUMERATOR – ASC admissions experiencing a burn prior to discharge.
ASC_1_DENOMINATOR – All ASC admissions.
ASC_2_NUMERATOR – ASC admissions experiencing a fall within the confines of the ASC.
ASC_2_DENOMINATOR – All ASC admissions.
ASC_3_NUMERATOR – All ASC admissions experiencing a wrong site, wrong side, wrong patient,
wrong procedure, or wrong implant.
ASC_3_DENOMINATOR – All ASC admissions.
ASC_4_NUMERATOR – ASC admissions requiring a hospital transfer or hospital admission upon
discharge from the ASC.
ASC_4_DENOMINATOR – All ASC admissions.
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 to 75 years of age 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 18 years and older who had an improvement in visual function
achieved within90 days following cataract surgery, based on completing both a pre-operative and postoperative 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?
[

[

]

[

]

]

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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.
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 through the Hospital Quality Reporting (HQR) Data Submission File Upload .
[

]

All data transmitted pass through the following process:
1. The file(s) are checked for proper naming convention and file type.
a. 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 checks the file for errors, logging each one in the file, and then rejects the file
if any errors are found. The error log is attached to the “File Processing Complete” notification
email.
b. If no errors are found, the “File Processing Complete” notification email is sent and lists the
number of records processed in the file, after the system uploads the file and applies the data to
the given Payment Year.
3. Note that there are no ADD, UPDATE, or DELETE action-codes associated with the file. To correct
errors, you can either:
a. Enter the HQR Data Form for each individual facility and update the values as appropriate, or
b. Upload a corrected CSV file which will overwrite any existing values.
[

[

]

[

]

]

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your[Material inside brackets ([and]) is new to this Specificatio ns Ma nual versio n.]

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-2

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

A-3

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

A-4

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

A-5

ASC-13: Normothermia Outcome-Algorithm

A-6

ASC-13: Normothermia Outcome-Example Questions

A-7

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Appendix A-1

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

Follow-up
interval
of at least
10 years

Y

N
N
Exclude from
the
numerator

Exclude from
the
measure
population

Include in the
denominator
population

End

Y
Exclude from
the
measure
population

Adapted from algorithm provided by
clinical services group/HCA; January
2020

Include in the
numerator
population

For use with encounter dates 010123-123123;
Specifications Manual version 12.0
A-2

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
Denominator/Numerator
Measure Criteria
Circle One
Determination
1. Patient had a screening colonoscopy, without
Yes
Include in denominator population,
biopsy or polypectomy, and is ≥ 50 to ≤ 75 years
continue to 1(a)
of age on date of encounter
No
Exclude from denominator population
a) Documentation of medical reason(s) for not
Yes
Exclude from denominator population
recommending at least a 10-year follow-up
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
Yes
Include in numerator population
years for repeat colonoscopy is documented in
colonoscopy report
No
Exclude from numerator population

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ASC-9: Endoscopy/Polyp Surveillance: 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.

•

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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ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for
Normal Colonoscopy in Average Risk Patients-Fact Sheet
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 Above average risk patient
o Inadequate prep
o Family history of colon cancer
o 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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A-5

ASC-13: Normothermia Outcome
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
≥ 60 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

Recorded
body temperature ≥ 96.8°
Fahrenheit or
36° Celsius

Y

N

Exclude from the
measure
population

Y

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

Adapted from algorithm provided by
clinical services group/HCA; January 2020

End

N

Do not include in
Numerator

For use with encounter dates 010123-123123;
Specifications Manual version 12.0
A-6

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.

ASCQR Specifications Manual
Encounter dates 01-01-23 (1Q23) through 12-31-23 (4Q23) v12.0
CPT® only copyright 2022 American Medical Association. All rights reserved.

A-7

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 cannot be substituted with Arrival at PACU time; therefore, this patient should not
be included in the measure.
ASCQR Specifications Manual
Encounter dates 01-01-23 (1Q23) through 12-31-23 (4Q23) v12.0
CPT® only copyright 2022 American Medical Association. All rights reserved.

A-7

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.

ASCQR Specifications Manual
Encounter dates 01-01-23 (1Q23) through 12-31-23 (4Q23) v12.0
CPT® only copyright 2022 American Medical Association. All rights reserved.

Appendix B-1