Ambulatory Surgical Center Quality Reporting (ASCQR) Program

ASCQR Specifications Manual Version 14.0 Release Notes
Ambulatory Surgical Center Quality Reporting Specifications Manual
Release Notes Version 14.0
Release Notes Completed: June 10, 2024
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 01/01/2025, 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, 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 14.0 Release Notes
The notes in the tables below are organized to follow the Table of Contents in the Specifications Manual.

Introduction
Impacts: Acknowledgement
Rationale: This change is to update the access to the comprehensive listing of ICD-10-CM® codes.
Description of Change(s):
Acknowledgement
Change from: The International Classification of Diseases, 11th Revision, Clinical Modification (ICD-10CM®) 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-10CM® is an official Health Insurance Portability and Accountability Act standard.
To: The International Classification of Diseases, 11th Revision, Clinical Modification (ICD-10-CM®) is
published by the United States Government. A comprehensive listing of ICD-10-CM® codes may be
obtained on the Centers for Disease Control and Prevention (CDC) website. ICD-10-CM® is an official
Health Insurance Portability and Accountability Act standard.
_______________________________________________________________________________________
Impacts: Program Background
Rationale: This update is to remove Program Requirement, Data Collection and Submission, and other
program requirement language from the Specifications Manual. Information on program requirements is
sourced within other documents for the ASCQR Program on the QualityNet.cms.gov website. Additional
minor changes were updated to add clarification to the Program Background. Refer to the Program
Background document in the Specifications Manual for minor language updates.
Description of Change(s):
Program Background
Remove: Program Requirement related language.
Add:
Quality Reporting
The ASC Quality Reporting (ASCQR) Program seeks to collect data and publicly report on quality metrics
so that the information is available to support consumer decision-making and provider improvements
regarding the quality and efficiency of care in this setting.

Section 1 – Measure Information Forms
Impacts: ASC-1: Patient Burn
Rationale: This change is to remove outdated reference and add new reference to ensure that the most
current literature supports the measure as currently specified.
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ASCQR Specifications Manual Version 14.0 Release Notes
Description of Change(s):
Clinical Recommendation Statements
Change from: 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.
To: 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
guidelines for electrosurgical safety from the Association of periOperative Registered Nurses (AORN).
Rationale: This change is removing outdated reference and adding new reference to ensure that the most
current literature supports the measure as currently specified.
Change:
Selected References
Add: Croke L. Guideline for electrosurgical safety. AORN J. 2020 Jul;112(1): P9-P11.
doi:10.1002/aorn.13124. PMID: 32598069.
Remove: ECRI Institute. Electrosurgery Checklist. 2020.
Change from: National Fire Protection Association (NFPA). NFPA 99: Health Care Facilities Code. Quincy,
MA: NFPA, 2018.
To: National Fire Protection Association (NFPA). NFPA 99: Health Care Facilities Code. Quincy,
MA: NFPA, 2024.
_______________________________________________________________________________________
Impacts: ASC-2 Patient Fall
Rationale: This change is to update outdated references and add new references to ensure that most current
literature supports the measure as currently specified.
Description of Change(s):
Additional Instructions
Change from: 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 10, 2023.

]

To: 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 January 16, 2024.
Change from: National Quality Forum. List of Serious Reportable Events.
https://www.qualityforum.org/topics/sres/list_of_sres.aspx. Last accessed February 10,2023.

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ASCQR Specifications Manual Version 14.0 Release Notes
To: National Quality Forum. List of Serious Reportable Events.
https://www.qualityforum.org/topics/sres/list_of_sres.aspx. Last accessed January 16, 2024.
Add: Valencia Morales DJ, Laporta ML, Johnson RL, Schroeder DR, Sprung J, Weingarten TN. A CaseControl Study of Accidental Falls During Surgical Hospitalizations. Am Surg. 2023 Jan;89(1):61-68. doi:
10.1177/00031348211011114. Epub 2021 Apr 18. PMID: 33870764.
_______________________________________________________________________________________
Impacts: ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant
Rationale: This change is to update outdated references to ensure that most current literature supports the
measure as currently specified.
Description of Change(s):
Selected References
Change from: 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 10, 2023.
To: Joint Commission. Universal Protocol For Preventing Wrong Site, Wrong Procedure, Wrong Person
Surgery. Available at https://www.jointcommission.org/standards/universal-protocol. Last accessed January
19, 2024.
Change from: 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/aboutacs/statements/93-surgery-checklists. Last accessed February 10, 2023.
To: 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.jointcommission.org/standards/universal-protocol. Last accessed January 19, 2024.
Change from: AORN. AORN Position Statement on Preventing Wrong-Patient, Wrong-Site, WrongProcedure Events. https://www.aorn.org/guidelines/clinical-resources/position-statements. Last accessed
February 10, 2023.
To: AORN. AORN Position Statement on Preventing Wrong-Patient, Wrong-Site, Wrong- Procedure
Events. https://www.aorn.org/guidelines/clinical-resources/position-statements.. Last accessed January 19,
2024.
Change from: National Quality Forum. List of Serious Reportable Events.
https://www.qualityforum.org/Topics/SREs/List_of_SREs.aspx. Last accessed February 10, 2023
[

.]

To: National Quality Forum. List of Serious Reportable Events.
https://www.qualityforum.org/Topics/SREs/List_of_SREs.aspx. Last accessed January 19, 2024.
_______________________________________________________________________________________
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ASCQR Specifications Manual Version 14.0 Release Notes
Impacts: ASC-4: All-Cause Hospital Transfer/Admission
Rationale: This change is to update language that supports the measure as currently specified.
Description of Change:
Selection Bias
Remove: Selected states have expressed an interest in the public reporting of such events.
_______________________________________________________________________________________
Impacts: ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy
in Average Risk Patients
Rationale: This change is to update ICD-10-CM® codes in the Measure Information Form to align with
current code updates. The update removes code Z83.71 and adds four additional codes Z83.710, Z83.711,
Z83.718, and Z83.719, to the Denominator Criteria.
Description of Change(s):
Denominator Criteria (Eligible Cases)
Change from:
Patients aged ≥ 45 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
To:
Patients aged ≥ 45 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: Z83.710, Z83.711, Z83.718, Z83.719, Z86.010, Z80.0, Z85.038
_______________________________________________________________________________________
Impacts: ASC-12: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy
Rationale: This update is to align language across the Claims-based Measure Information Forms in response
to stakeholder feedback.
Description of Change(s):
Measure Information Form
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ASCQR Specifications Manual Version 14.0 Release Notes
Change: Please refer to the Measure Information Form for updated language
_______________________________________________________________________________________
Impacts: ASC-13: Normothermia
Rationale: This update is to add language to specify the numerator exclusions for ASC-13 in response to
stakeholder inquiries requesting further clarification.
Description of Change(s):
Numerator Exclusions
Change from: None
To: Patients with a postoperative body temperature less than 96.8 Fahrenheit/36 Celsius; patients whose
body temperature was recorded sixteen minutes or more after arrival in PACU; patients with no
postoperative body temperature recorded.
Rationale: This change is to remove outdated reference and add new reference to ensure that most current
literature supports the measure as currently specified.
References
Add:
Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG,
Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH,
Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and
management of patients undergoing noncardiac surgery: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Dec
9;130(24): e278-333.
Remove:
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.
_______________________________________________________________________________________
Impacts: ASC-14: Unplanned Anterior Vitrectomy
Rationale: This change is to remove outdated reference and add new reference to ensure that most current
literature supports the measure as currently specified.
Description of Change(s):
References
Add:
American Academy of Ophthalmology Preferred Practice Pattern Cataract/Anterior Segment Panel. Cataract
in the Adult Eye Preferred Practice Pattern. Ophthalmology. 2022 Jan;129(1):P1-P126.
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ASCQR Specifications Manual Version 14.0 Release Notes
Remove:
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
_______________________________________________________________________________________
Impacts: ASC-17 Hospital Visits After Orthopedic Ambulatory Surgical Center Procedures.
Rationale: This update is to align language across the Claims-based Measure Information Forms in response
to stakeholder feedback.
Description of Change(s):
Measure Information Form
Change: Please refer to the Measure Information Form for updated language.
_______________________________________________________________________________________
Impacts: ASC-18: Hospital Visits After Urology Ambulatory Surgical
Rationale: This update is to align language across the Claims-based Measure Information Forms in response
to stakeholder feedback
Description of Change (s):
Measure Information Form
Change: Please refer to the Measure Information Form for updated language.
_______________________________________________________________________________________
Impacts: ASC-19:
Rationale: This update is to align language across the Claims-based Measure Information Forms in response
to stakeholder feedback.
Description of Change (s):
Measure Information Form
Change: Please refer to the Measure Information Form for updated language.

Appendix A – Tools and Resources
Impacts: ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy
in Average Risk Patients - Denominator Codes.
Rationale: This change is to update ICD-10-CM® codes in the Measure Information Form align with
current code updates. The update removes code Z83.71 and adds four additional codes Z83.710, Z83.711,
Z83.718, and Z83.719, to the Denominator Criteria.
Description of Change(s):
Denominator Criteria
Change from:
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ASCQR Specifications Manual Version 14.0 Release Notes
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
To:
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
Z83.710: Family history of adenomatous and serrated polyps
Z83.711: Family history of hyperplastic colon polyps
Z83.718: Other family history of colon polyps
Z83.719: Family history of colon polyps, unspecified
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
_______________________________________________________________________________________
Impacts: ASC-13: Normothermia Outcome Algorithm
Rationale: This update to the measure algorithm is to ensure accurate interpretation of the measure as
currently specified.
Description of Changes(s):
Algorithm
Please see the algorithm in the Tools and Resources section.
_______________________________________________________________________________________
Impacts: ASC-13: Normothermia Outcome Example Questions
Rationale: This update is to add language to specify the numerator exclusions for ASC-13 in response to
stakeholder inquiries requesting further clarification.
Description of Change(s):
Step 2: Determine how many patients in the Denominator population had the required body temperature
within 15 minutes of arriving in the PACU (Numerator)
Change from: 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.

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ASCQR Specifications Manual Version 14.0 Release Notes
To: If the patient had a recorded body temperature greater than or equal to 96.8°F or 36°C within 15
minutes of arrival in the PACU, then the patient can be included in the Numerator. If there was no
postoperative temperature recorded, or the temperature was recorded 16 minutes or more after arrival in the
PACU, then the patient should be excluded from the Numerator.
Rationale: This change is to update language for consistency in how patients in the different scenarios are
presented.
Description of Change(s):
Scenario 3
Change from: Private pay patient received general anesthesia.
To: Patient received general anesthesia.
Scenario 4
Change from: Medicare patient started epidural in pre-op holding at 0800.
To: Patient started epidural in pre-op holding at 0800.

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Ambulatory Surgical Center Quality Reporting
Specifications Manual
Version 14.0
Encounter Dates: 01-01-25 (1Q25) through 12-31-25 (4Q25)
OMB #0938-1270 Expiration Date: 08-31-2025

Table of Contents
Acknowledgement ................................................................................................................................................. i
Program Background .......................................................................................................................................... ii
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 .................................................................................................................. 1-19
ASC-14: Unplanned Anterior Vitrectomy ...................................................................................................... 1-22
[

ASC-20: COVID-19 Vaccination Coverage Among Health Care Personnel ................................................. 1-36

]

Measure Information Forms-Claims-Based Measures
ASC-12: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient
Colonoscopy Introduction ............................................................................................................................... 1-15
ASC-17: Risk-Standardized Hospital Visits within 7 Days After Orthopedic Ambulatory Surgical Center
Procedures Introduction .................................................................................................................................. 1-24
ASC-18: Risk-Standardized Hospital Visits within 7 Days After Urology Ambulatory Surgical Center
Procedures Introduction ...................................................................................................................................1-28
ASC-19: Facility-Level 7-Day Hospital Visits after General Surgery Procedures Performed
at Ambulatory Surgical Centers Introduction .................................................................................................. 1-32
Section 2: Sampling Specifications ................................................................................................................... 2-1
Section 3: Quality Data Transmission .............................................................................................................. 3-1
Appendix A: Tools and Resources ................................................................................................................... A-1

[

Appendix B: Reserved for Future Use..............................................................................................................B-1
Appendix C: ASC Measures Quick Reference Guide………………………………………………………C-1

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Acknowledgement
The Ambulatory Surgical Center Quality Reporting (ASCQR) Specifications Manual was developed by
the Centers for Medicare & Medicaid Services (CMS) to provide a uniform set of quality measures 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 2024 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 comprehensive listing of ICD-10-CM codes may be obtained on the
Centers for Disease Control and Prevention (CDC) website. 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.

_________________________________________________________________________________________
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Program Background
CMS Quality Initiatives
Background
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, authorized the
Centers for Medicare & Medicaid Services (CMS) to have a program under which ASCs may report data on
the quality of their care using standardized measures to receive the full annual payment update (APU) under
the Ambulatory Surgical Center (ASC) payment system. The program established under the Calendar Year
(CY) 2012 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center (ASC) Final
Rule, with Comment Period (CMS-1525-FC) and supported by this manual is the Ambulatory Surgical
Center Quality Reporting (ASCQR) Program.
Quality Reporting
The ASC Quality Reporting (ASCQR) Program seeks to collect data and publicly report on quality metrics so
that the information is available to support consumer decision-making and provider improvements regarding
the quality and efficiency of care in this setting.

Related Activities
Measure Development
Sections 1833(i)(7)(B) and 1833(t)(17)(C)(i) of the Medicare Improvements and Extension Act under Division
B, Title I of the Tax Relief Health Care Act (MIEA–TRHCA) of 2006, requires the Secretary to develop
measures appropriate for the measurement of the quality of care furnished by ASCs, and that measures reflect
consensus among affected parties. Program measures are not required to be endorsed by any national
consensus-based entity.

[

]

[

Measures Management System
The Measures Management System (MMS) is a standardized system for developing and maintaining the quality
measures used in various CMS initiatives and programs. MMS also supports quality-related activities across the
agency. Quality measures are tools that help improve the quality of healthcare through an approach that is
consistent and accountable. The primary goals of the MMS are to:
• Provide support and guidance to measure developers to help them produce high caliber healthcare quality
measures, and
• Educate and inform interested parties to promote involvement in and awareness of the Measure Lifecycle.
Outpatient and Ambulatory Surgery Consumer Assessment (OAS CAHPS)
The OAS CAHPS initiative was developed as a patient-experience-of-care survey for patients who had
surgery or a procedure at a hospital outpatient department (HOPD) or an ambulatory surgery center (ASC).
Prior to OAS CAHPS, there was no standardized survey instrument to assess patient experience with
outpatient surgical care received at HOPDs and ASCs. Facilities contract with a CMS-approved OAS
CAHPS Survey vendor to conduct the survey. A list of approved survey vendors is available at the
following link: https://oascahps.org/General-Information/Approved-Survey-Vendors.
Beginning with Calendar Year (CY) 2023 reporting period, ASCs were provided the opportunity to
voluntarily submit data for the OAS CAHPS survey, as well as voluntary reporting for CY 2024.
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Beginning with CY 2025 reporting period, ASCs will be required to report quarterly data by the submission
deadlines provided on the OAS CAHPS website.
Paperwork Reduction Act (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 C426-05, Baltimore, MD 21244-1650.

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Section 1- Measure Information Forms

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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Section 1- Measure Information Forms

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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Section 1- Measure Information Forms

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 guidelines for electrosurgical safety from the Association of periOperative
Registered Nurses (AORN).
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://pubs.asahq.org/anesthesiology/article/118/2/271/13592/Practice-Advisory-for-thePrevention-and.
Guidance for the prevention of surgical fire has also been published by 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)
system 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.
Croke L. Guideline for electrosurgical safety. AORN J. 2020 Jul;112(1):P9-P11.
doi:10.1002/aorn.13124. PMID: 32598069.
National Fire Protection Association (NFPA). NFPA 99: Health Care Facilities Code.
Quincy, MA: NFPA, 2024.
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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Section 1- Measure Information Forms

•

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 1,000 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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Section 1- Measure Information Forms

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) system 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. Preventing Fall-Related Injuries. August 15, 2018.
•
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 January 16, 2024.
•
National Quality Forum. List of Serious Reportable Events.
https://www.qualityforum.org/topics/sres/list_of_sres.aspx. Last accessed January 16,
2024.
•
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.
•
Amador LF, Loera JA. Preventing Postoperative Falls in the Older Adult. J Am Coll
Surg. 2007 Mar; 204(3):447-453.
• Fritz BA, King CR, Mehta D, Somerville E, Kronzer A, Ben Abdallah A, Wildes T,
Avidan MS, Lenze EJ, Stark S; ENGAGES Research Group. Association of a
Perioperative Multicomponent Fall Prevention Intervention With Falls and Quality of Life
After Elective Inpatient Surgical Procedures. JAMA Netw Open. 2022 Mar 1;
5(3):e221938.
•
Kronzer VL, Wildes TM, Stark SL, Avidan MS. Review of perioperative falls. Br J
Anaesth. 2016 Dec; 117(6):720-732.
•
Croke L. Preventing Falls Among Perioperative Patients. AORN J. 2022 Nov; 116(5):
P8-P10.
•
Kaiser TJ, Shanley E, Denninger TR, Reuschel B, Kissenberth MJ, Tolan SJ, Thigpen
CA, Pill SG. Preoperative screening in patients having elective shoulder surgery reveals
a high rate of fall risk. J Shoulder Elbow Surg. 2021 Jul; 30(7S):S84-S88.
•
Valencia Morales DJ, Laporta ML, Johnson RL, Schroeder DR, Sprung J, Weingarten
TN. A Case-Control Study of Accidental Falls During Surgical Hospitalizations. Am
Surg. 2023 Jan;89(1):61-68. doi: 10.1177/00031348211011114. Epub 2021 Apr 18.
PMID: 33870764.
•

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Section 1- Measure Information Forms

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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Section 1- Measure Information Forms

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)
system 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 January
19, 2024.
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. Last accessed January
19, 2024.
AORN. AORN Position Statement on Preventing Wrong-Patient, Wrong-Site, WrongProcedure Events. https://www.aorn.org/guidelines/clinical-resources/position-statements.
Last accessed January 19, 2024.
Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC:
National Academy Press, 2000.
National Quality Forum. List of Serious Reportable Events.
https://www.qualityforum.org/Topics/SREs/List_of_SREs.aspx. Last accessed January
19, 2024.
World Health Organization. WHO Guidelines for Safe Surgery 2009.
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.]

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Section 1- Measure Information Forms

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.
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. It should be noted that issues identified preoperatively are included
because they also represent good patient care when a hospital transfer/admission is necessary.
[

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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Section 1- Measure Information Forms

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)
system 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 hemorrhage 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 Orthopedic
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 45 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 45 to 75 years of age receiving screening colonoscopy
without biopsy or polypectomy.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 45 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: Z83.710, Z83.711, Z83.718, Z83.719, 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


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Section 1- Measure Information Forms

colonoscopy report.


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) system 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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Section 1- Measure Information Forms

Measure Information Form
Measure Title: Cataracts – Improvement in Patient’s Visual Function within 90 Days Following
Cataract Surgery
Measure ID #: ASC-11
ASCs have the option to voluntarily collect and submit data for ASC-11 for the CY 2024 payment
determination and subsequent years, as finalized in the CY 2023 OPPS/ASC Final Rule (Vol. 87, pp.
72118-72120).
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) system 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.
For the purposes of this measure, survey instruments that may be used to assess changes in a patient’s visual
function are limited to the National Eye Institute Visual Function Questionnaire-25 (NEI-VFQ-25)
(http://www.rand.org/health/surveys_tools/vfq.html) and two versions of the Visual Function Index, VF-14
(https://www.ncbi.nlm.nih.gov/books/NBK259054/bin/appd-m4.pdf) and VF-8R
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Section 1- Measure Information Forms

(https://www.aao.org/Assets/a14d8830-e753-4031-a22b-901fb4fe9498/635863021754000000/pre-cataractsurgery-vf-8r-patient-questionnaire-pdf?inline1). 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 (Healthcare Common Procedure Coding System [HCPCS]: G0913).
Definition of Performance Not Met: Improvement in visual function not achieved within 90 days
following cataract surgery (HCPCS: G0915).
Denominator Exception: Patient care survey was not completed by patient (HCPCS: G0914).

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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 colonoscopy measure estimates a facility-level rate of risk- standardized, allcause, unplanned hospital visits within seven days of an outpatient colonoscopy performed at an
ambulatory surgery center (ASC) among Medicare Fee-for-Service (FFS) patients aged 65 years and
older.
Rationale: The colonoscopy measure aims to 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 assesses
quality and inform quality improvement. CMS uses a comprehensive method for development, testing, and
creating final specifications for the measure. For initial measure specifications, CMS assembled a
multidisciplinary team of clinicians, health services researchers, and statisticians and convened, through a
public process, a national technical expert panel (TEP) consisting of patients, surgeons, methodologists,
researchers, and providers. CMS also held a public comment period soliciting stakeholder input on the
measure methodology.
Type of Measure: Outcome
Improvement Noted As: A decrease in the facility-level risk-standardized unplanned hospital visit
rate. A 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 below, under the Measure Calculation section.
The outcome for the measure is all-cause, unplanned hospital visits within seven days of an
outpatient colonoscopy performed 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 the measure includes low-risk colonoscopies performed in the outpatient
Setting at an ASC for Medicare FFS patients aged 65 years and older. For implementation in the ASCQR
Program, the measure will be calculated among ASCs.
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Included Populations:
The target population for the measure is Medicare FFS patients aged 65 years and older undergoing an
outpatient colonoscopy who have been enrolled in Part A and Part B Medicare for 12 months or more 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 Colonoscopy Measure
Methodology QualityNet page: https://qualitynet.cms.gov/asc/measures/colonoscopy/methodology .
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 Colonoscopy Measure
Methodology QualityNet page for detailed measure cohort exclusion criteria with the accompanying
data dictionary containing the most current exclusions codes, located here:
https://qualitynet.cms.gov/asc/measures/colonoscopy/methodology.
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 seven 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 Colonoscopy 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 measure adjusts for differences across facilities in
patient demographics, clinical factors, and procedure-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 TEP and expert clinical input.
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The risk-adjustment model includes 15 patient-level variables (age, concomitant upper gastrointestinal
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-10CM) 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.
Table 1: Patient-Level Risk-Adjustment Variables
Patient-Level Variables
Demographics

Risk-Adjusted Variables
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
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 seven 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 on the Colonoscopy Measure Archived Resources QualityNet page:
https://qualitynet.cms.gov/asc/measures/colonoscopy/resources#tab2.
[

]

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.

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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 seven-day risk-standardized unplanned hospital visit rates using
hierarchical logistic regression modeling (a form of hierarchical generalized linear modeling). 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 seven days of the procedure for age, procedural factors, and selected clinical covariates. At
the facility level, it estimates the facility-specific intercepts as arising from a normal distribution.
The facility-specific intercept represents the underlying risk of a hospital visit within seven 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 available
on the Colonoscopy Measure Archived Resources QualityNet page:
https://qualitynet.cms.gov/asc/measures/colonoscopy/resources#tab2.
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.
Statistical Science. 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 a post-anesthesia care unit (PACU).
Numerator: Surgery patients with a body temperature equal to or greater than 96.8 Fahrenheit/36 Celsius
recorded within 15 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: Patients with a postoperative body temperature less than 96.8° Fahrenheit (or 36.0°
Celsius); patients whose body temperature was recorded 16 minutes or more after arrival in PACU; patients with
no postoperative body temperature recorded.
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.
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* 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.
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) system
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, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG,
Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH,
Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and
management of patients undergoing noncardiac surgery: A report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Dec
9;130(24):e278–333.
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
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Section 1- Measure Information Forms

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.
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) system
at https://hqr.cms.gov via an online tool available to authorized users.
References:
American Academy of Ophthalmology Preferred Practice Pattern Cataract/Anterior Segment Panel. Cataract
in the Adult Eye Preferred Practice Pattern. Ophthalmology. 2022 Jan;129(1):P1-P126.

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Section 1- Measure Information Forms

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.
Song C, Baharozian CJ, Hatch KM, Grassett GC, Talamo JH. Rate of Unplanned Vitrectomies in
Femtosecond Laser-Assisted Cataract Surgery Compared to Conventional Phacoemulsification. J
Refract Surg. 2018 Sep 1; 34(9):610-614.
[

]

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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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 orthopedic measure estimates a facility-level rate of risk-standardized, all-cause, unplanned
hospital visits within seven days of an orthopedic surgery at an ambulatory surgery center (ASC) among
Medicare Fee-for-Service (FFS) patients aged 65 years and older.
Rationale: Nearly 70 percent 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). The measure aims to
improve transparency, inform patients and providers, and foster quality improvement efforts for hospital visits
following orthopedic surgery at ASCs. CMS uses a comprehensive method for development, testing, and
creating final specifications for the measure. For initial measure specifications, CMS assembled a
multidisciplinary team of clinicians, health services researchers, and statisticians and convened, through a public
process, a national technical expert panel (TEP) consisting of patients, surgeons, methodologists, researchers,
and providers. CMS also held a public comment period soliciting stakeholder input on the measure methodology.
Type of Measure: Outcome
Improvement Noted As: A decrease in the facility-level risk-standardized unplanned hospital visit rate. A lower
rate indicates better quality.
Numerator Statement:
The orthopedic 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 the
Measure Calculation section.
The outcome for this measure is all-cause, unplanned hospital visits within seven days of orthopedic surgery
performed 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 the 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 12 months or more prior to the date
of surgery to ensure the availability of data for identifying comorbidities for risk adjustment.
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The measure includes procedures that are routinely performed at ASCs, involve increased risk of post- surgery
hospital visits, and are routinely performed by orthopedists. Cohort codes are located in the data dictionary that
accompanies the Measure Updates and Specifications Report, available on the Orthopedic Measure Methodology
QualityNet page: https://qualitynet.cms.gov/asc/measures/orthopedic/methodology.
Exclusion:
Surgeries for patients who survived at least seven days but were not continuously enrolled in Medicare FFS Parts
A and B in the seven days after the surgery. The measure excludes these patients to ensure all patients have full
data available for outcome assessment.
See the Measure Updates and Specifications Report available on the Orthopedic Measure Methodology
QualityNet page for detailed measure cohort exclusion criteria with the accompanying data dictionary containing
the most current exclusion codes, located here: https://qualitynet.cms.gov/asc/measures/orthopedic/methodology.
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 seven 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 Updates and Specifications Report
available on the Measure Methodology QualityNet page:
ttps://qualitynet.cms.gov/asc/measures/orthopedic/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 technical expert panel 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
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diagnosis code, we define comorbidity variables using CMS Condition Categories, which are clinically
meaningful groupings of many thousands of ICD-10-CM diagnosis codes.
Table 1: Patient-Level Risk-Adjustment Variables
Patient-Level Variables
Demographics

Comorbidities

Surgical Procedural
Complexity

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

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Full details of the development of the risk standardization model for this measure are available on the Orthopedic
Measure Archived Resources QualityNet page: https://qualitynet.cms.gov/asc/measures/orthopedic/resources
#tab2.
[

]

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 seven-day risk-standardized, all-cause, unplanned hospital visit rate following
orthopedic surgery
Measure Calculation:
The measure estimates facility-level seven-day risk-standardized unplanned hospital visit rates using hierarchical
logistic regression modeling (a form of hierarchical generalized linear modeling). 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 seven days of the
surgery for age, procedural factors, and selected clinical covariates. At the facility level, it estimates the facilityspecific intercepts as arising from a normal distribution. The facility intercept represents the underlying risk of a
hospital visit within seven 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 available on the Orthopedic
Measure Methodology QualityNet page: https://qualitynet.cms.gov/asc/measures/orthopedic/methodology.
[

]

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: Hospital Visits after Urology Ambulatory Surgical Center Procedures
Measure ID #: ASC-18
Measure Set: CMS Outcome Measures (Claims-Based)
Description: The urology measure estimates a facility-level rate of risk-standardized, all-cause, unplanned
hospital visits within seven days of a urology surgery at an Ambulatory Surgery Center (ASC) among
Medicare fee-for-service (FFS) patients aged 65 years and older.
Rationale: Nearly 70 percent 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. CMS uses a comprehensive method for
development, testing, and creating final specifications for the measure. For initial measure specifications,
CMS assembled a multidisciplinary team of clinicians, health services researchers, and statisticians and
convened, through a public process, a national technical expert panel (TEP) consisting of patients, surgeons,
methodologists, researchers, and providers. CMS also held a public comment period soliciting stakeholder
input on the measure methodology.
Type of Measure: Outcome
Improvement Noted As: A decrease in the facility-level risk-standardized unplanned hospital visit rate. A lower
rate indicates better quality.
Numerator Statement:
The urology 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
the Measure Calculation section.
The outcome for the measure is all-cause, unplanned hospital visits within seven 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 the 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 12 months or more prior to
the date of surgery to ensure the availability of data for identifying comorbidities adjustment.
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Section 1- Measure Information Forms

The measure includes surgeries that are routinely performed at ASCs, involve increased risk of post-surgery
hospital visits, and are routinely performed by urologists. Cohort codes are located in the data dictionary that
accompanies the Measure Updates and Specifications Report, available on the Urology Measure
Methodology QualityNet page: https://qualitynet.cms.gov/asc/measures/urology/methodology.
Exclusion:

Surgeries for patients who survived at least seven days but were not continuously enrolled in Medicare FFS Parts A
and B in the seven days after the surgery. The measure excludes these patients to ensure all patients have full data
available for outcome assessment.

See the Measure Updates and Specifications Report available on the Urology Measure Methodology
QualityNet page for detailed measure cohort exclusion criteria with the accompanying data dictionary
containing the most current exclusion codes, located here:
https://qualitynet.cms.gov/asc/measures/urology/methodology.
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 seven 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 Updates and
Specifications Report available on the Urology Measure Methodology QualityNet page:
https://qualitynet.cms.gov/asc/measures/urology/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 TEP and expert clinical input.
The risk-adjustment model has seven patient-level variables (age and six comorbidity variables), number of
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Section 1- Measure Information Forms

qualifying procedures, and work relative value units (RVU) to adjust for surgical complexity (see Table 1).
With the exception of benign prostatic hyperplasia with obstruction which we define using an individual
ICD-10-CM diagnosis code, we define comorbidity variables using CMS Condition Categories, which are
clinically meaningful groupings of many thousands of ICD-10-CM diagnosis codes.
Table 1: Patient-Level Risk-Adjustment Variables
Patient-Level Variables
Demographics

Comorbidities

Number of Qualifying
Procedures
Patient-Level Variables
Surgical Procedural
Complexity

Risk-Adjusted Variables
Age (years greater than 65)
Benign prostatic hyperplasia with obstruction
Complications of specified implanted device or graft
Poisonings and inflammatory allergic reactions
Major symptoms, abnormalities
Parkinson's and Huntington's diseases; seizure disorders and convulsions
Ischemic heart disease
Defined as 2 vs. 1, 3, or more vs. 1
Risk-Adjusted Variables
Work RVU

Full details of the development of the risk standardization model for this measure are available on
the Urology Measure Archived Resources QualityNet page:
https://qualitynet.cms.gov/asc/measures/urology/resources #tab2.
[

]

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 seven-day risk-standardized, all-cause, unplanned hospital visit rate
following urology surgery.
Measure Calculation:
The measure estimates facility-level, seven-day risk-standardized unplanned hospital visit rates using
hierarchical logistic regression modeling (a form of hierarchical generalized linear modeling). 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 seven 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
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Section 1- Measure Information Forms

represents the underlying risk of a hospital visit within seven 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 available on the Urology Measure Archived
Resources QualityNet page: https://qualitynet.cms.gov/asc/measures/urology/resources#tab2.
[

]

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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Section 1- Measure Information Forms

Measure Information Form
Performance Measure Name: Facility-Level-7-Day Hospital Visits after General Surgery
Procedures Performed at Ambulatory Surgical Centers
Measure ID #: ASC-19
Measure Set: CMS Outcome Measures (Claims-Based)
Description: The general surgery measure estimates a facility-level rate of risk-standardized, allcause, unplanned hospital visits within seven days of a general surgery at an Ambulatory Surgery
Center (ASC) among Medicare fee-for-service (FFS) patients aged 65 years and older.
Rationale: Nearly 70 percent 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. CMS
uses a comprehensive method for development, testing, and creating final specifications for the
measure. For initial measure specifications, CMS assembled a multidisciplinary team of
clinicians, health services researchers, and statisticians and convened, through a public process, a
national technical expert panel (TEP) consisting of patients, surgeons, methodologists,
researchers, and providers. CMS also held a public comment period soliciting stakeholder input
on the measure methodology.
Type of Measure: Outcome
Improvement Noted As: A decrease in the facility-level risk-standardized unplanned hospital
visit rate. A lower rate indicates better quality.
Numerator Statement:
The general surgery measure does not have a traditional numerator and denominator like a
process measure (e.g., percentage of adult patients with diabetes aged 18 to 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 the general surgery measure is all-cause, unplanned hospital visits within seven
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 12 months
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Section 1- Measure Information Forms

or more 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. [Cohort codes are
located in the data dictionary that accompanies the Measure Updates and Specifications Report,
available on the General Surgery Measure Methodology QualityNet page:
https://qualitynet.cms.gov/asc/measures/surgery/methodology.
Exclusion:
Surgeries for patients who survived at least seven days but were not continuously enrolled in
Medicare FFS Parts A and B in the seven days after the surgery. The measure excludes these
patients to ensure all patients have full data available for outcome assessment.
The full list of exclusions is located in the data dictionary that accompanies the Measure Updates
and Specifications Report, available on the General Surgery Measure Methodology QualityNet
page: https://qualitynet.cms.gov/asc/measures/surgery/methodology.
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 seven
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 Updates and Specifications Report available on the General Surgery Measure
Methodology QualityNet page: https://qualitynet.cms.gov/asc/measures/surgery/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
ASCQR Specifications Manual
Encounter dates 01-01-25 (1Q25) through 12-31-25 (4Q25) v14.0
CPT® only copyright 2024 American Medical Association. All rights reserved.

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Section 1- Measure Information Forms

and the literature; a preliminary list of risk factors was developed and then revised based on a
technical expert panel 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, 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)
Abdomen and its contents Alimentary tract
Procedure Type
Breast Skin/soft tissue Wound Vascular
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 disorders Stroke
Chronic lung disease Pneumonia
Dialysis or sever chronic kidney disease Benign prostatic
hyperplasia
Comorbidities
Cellulitis, local skin infection
Major traumatic fracture or internal injury Complicates of care
Chronic anticoagulant use Opioid abuse
Surgical Procedural
Work RVU
Complexity
Full details of the development of the risk standardization model for this measure are available on
the General Surgery Measure Archived Resources QualityNet page:
https://qualitynet.cms.gov/asc/measures/surgery/resources#tab2.
[

]

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 seven-day risk-standardized, all-cause, unplanned hospital visit
rate following general surgery.
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Section 1- Measure Information Forms

Measure Calculation:
The measure estimates facility-level, seven-day risk-standardized unplanned hospital visit rates
using hierarchical logistic regression modeling (a form of hierarchical generalized linear
modeling). 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 seven 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 seven days after a general 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 available on the Surgery
Measure Archived Resources QualityNet page:
https://qualitynet.cms.gov/asc/measures/surgery/resources#tab2.
.[

]

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.

ASCQR Specifications Manual
Encounter dates 01-01-25 (1Q25) through 12-31-25 (4Q25) v14.0
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Section 1- Measure Information Forms

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: Percentage of All Core Healthcare Personnel (HCP) eligible to work at the ASC for at least
one day of the self-selected week, in each month of quarterly data reporting, who received a complete
primary vaccination series and are up to date with CDC recommended COVID– 19 vaccines*.
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 Participation from the banner
options.
Denominator: Number of HCP eligible to work in the ASC for at least one day during the reporting period,
excluding persons with contraindications to COVID–19 vaccination that are described by the CDC.
[

]

Numerator: Cumulative number of HCP eligible to work in the ASC for at least one day during the reporting
period who received a complete vaccination course and are up to date with CDC recommended COVID– 19
vaccines.
[

Definitions:
All Core HCP: Sum of Employees (staff on facility payroll), Licensed independent practitioners: Physicians,
advanced practice nurses, & physician assistants, and adult students/trainees & volunteers.
Complete Primary Series: A complete primary series is defined as receiving a 2-dose series of a monovalent
COVID-19 vaccine OR a single dose of Janssen OR a single dose of bivalent vaccine OR a single dose of
2023-2024 updated COVID-19 vaccine.
*Information on Key Terms and Up to Date Vaccination status definitions and examples can be found
on the CDC site. Refer to the CDC site at least once per quarter. Report vaccination data according to
the definitions corresponding to the week of data being reported.

Hospital ASCQR Specifications Manual
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Section 2- Sampling Specifications

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 2024 reporting period.
**For ASCs with fewer than 63 cases, the total population of cases is required.

8

Sampling Frequency Values
When submitting data via CSV as described in the Quality Data Transmission section, sampling frequency is
set by numeric values rather than the text value. The table below specifies these values while the table above
provides the minimum sample size based on the sampling frequency selected.
[

]

Sampling Frequency Value

Sampling Frequency

1

Monthly

2

Quarterly

3

Not Sampled

4
N/A - Submission not required***
***If “4 – N/A Submission not required” is used as a sampling frequency then your population size must be
zero. If your population size is not zero, then a frequency value of “3” should be selected, to indicate that you
have not sampled, and are reporting data based on the entire population.
[

]

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Section 3- Quality Data Transmission

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 is transmitted to the Hospital Quality Reporting Data Form. All data submitted
must 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 within 90 days following cataract surgery, based on completing both a pre-operative and postoperative visual function instrument.
[

[

]

[

]

]

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Section 3- Quality Data Transmission

ASC_11_DENOMINATOR – All patients 18 years and older who had cataract surgery and completed
both a pre-operative and post-operative visual function instrument.
ASC_13_POP_SIZE – What was your facility’s total population?
ASC_13_SAMP_SIZE – What was your facility’s sample size?
ASC_13_SAMP_FREQ – What was your facility’s sampling frequency?
ASC_13_NUMERATOR – Surgery patients with a body temperature equal to or greater than 96.8
Fahrenheit/36 Celsius recorded within fifteen minutes of Arrival in PACU.
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
represents 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.
[

[

]

[

]

]

ASCQR Specifications Manual
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3-2

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 ≥ 45 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 ≥ 45
to ≤ 75 years

Y

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

Follow-up
interval
of at least
10 years

Biopsy or
polypectomy
performed

N

Y

N
N

Follow-up
interval
of at least
10 years

Exclude from
the
numerator

Exclude from
the
measure
population

Include in the
denominator
population

End

Y
Exclude from
the
measure
population

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

Include in the
numerator
population

For use with encounter dates 010125-123125;
Specifications Manual version 14.0
A-2

Appendix A: Tools and Resources

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 ≥ 45 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
Continue to Question 2
inadequate prep or if age is documented as a No
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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A-3

Appendix A: Tools and Resources

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 ≥ 45 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
Z83.710: Family history of adenomatous and serrated polyps
Z83.711: Family history of hyperplastic colon polyps
Z83.718: Other family history of colon polyps
Z83.719: Family history of colon polyps, unspecified
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

ASCQR Specifications Manual
Encounter dates 01-01-25 (1Q25) through 12-31-25 (4Q25) v14.0
CPT® only copyright 2024 American Medical Association. All rights reserved.

A-4

Appendix A: Tools and Resources

ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for
Normal Colonoscopy in Average Risk Patients-Fact Sheet
Description: Percentage of patients aged 45to 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 45 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.

ASCQR Specifications Manual
Encounter dates 01-01-25 (1Q25) through 12-31-25 (4Q25) v14.0
CPT® only copyright 2024 American Medical Association. All rights reserved.

A-5

Appendix A: Tools and Resources

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
Start

Patient had a surgical
procedure under general or
neuraxial anesthesia

Exclude from
Denominator

N

Y

Time from Start of
anesthesia to End of
anesthesia ≥ 60 minutes

N

Exclude from
Denominator

Y

Exclude from
Denominator

Y

Documentation of
intentional hypothermia
by physician/physician’s
assistant/advance
practice nurse
N

Include in Denominator

Patient’s
postoperative body
temperature recorded

N

Exclude from
Numerator

N

Exclude from
Numerator

N

Exclude from
Numerator

Y

Patient’s
postoperative body
temperature recorded
within 15 minutes of
Arrival in PACU
Y

Patient’s
postoperative body
temperature ≥ 96.8°
Fahrenheit or 36°
Celsius
Y

Include in Numerator

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

End

For use with encounter dates 010125-123125;
Specifications Manual version 14.0
A-6

Appendix A: Tools and Resources

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 recorded body temperature greater than or equal to 96.8°F or 36°C within 15
minutes of arrival in the PACU, then the patient can be included in the Numerator. If there was
no postoperative temperature recorded, or the temperature was recorded 16 minutes or more
after arrival in the PACU, then the patient should be excluded from 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 01-01-25 (1Q25) through 12-31-25 (4Q25) v14.0
CPT® only copyright 2024 American Medical Association. All rights reserved.

A-8

Appendix A: Tools and Resources

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
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
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 01-01-25 (1Q25) through 12-31-25 (4Q25) v14.0
CPT® only copyright 2024 American Medical Association. All rights reserved.

A-8

Appendix B: Reserved for Future Use

Reserved for Future Use

ASCQR Specifications Manual
Encounter dates 01-01-25 (1Q25) through 12-31-25 (4Q25) v14.0
CPT® only copyright 2024 American Medical Association. All rights reserved.

Appendix B-1

Appendix C: ASC Measures Quick Reference Guide
Measure
ID
ASC-1

ASC-2

ASC-3

ASC-4

ASC-9

Measure Name
Patient Burn

Patient Fall

Measure
Type*
Outcome

Outcome

Wrong Site, Wrong Side,
Wrong Patient, Wrong
Procedure, Wrong
Implant

Outcome

All-Cause Hospital
Transfer/Admission

Outcome

Endoscopy/Polyp
Surveillance: Appropriate
Follow-Up Interval for
Normal Colonoscopy in
Average Risk Patients

Process

Data Sources
ASC medical records, as well as incident/
occurrence reports, and variance reports are
potential data sources. Data submitted through the
Hospital Quality Reporting (HQR) system at
https://hqr.cms.gov via an online tool available to
authorized users.
ASC medical records, as well as incident/
occurrence reports, and variance reports are
potential data sources. Data submitted through the
Hospital Quality Reporting (HQR) system at
https://hqr.cms.gov via an online tool available to
authorized users.
ASC medical records, as well as incident/
occurrence reports, and variance reports are
potential data sources. Data submitted through the
Hospital Quality Reporting (HQR) system at
https://hqr.cms.gov via an online tool available to
authorized users.
ASC medical records, as well as incident/
occurrence reports, and variance reports are
potential data sources. Data submitted through the
Hospital Quality Reporting (HQR) system at
https://hqr.cms.gov via an online tool available to
authorized users.
ASC medical records, as well as
incident/occurrence reports, and variance reports are
potential data sources. Use the CPT® codes
indicated in the Specifications Manual. Data
submitted through the Hospital Quality Reporting
(HQR) system at https://hqr.cms.gov via an online
tool available to authorized users.

Applicable Notes
All patients are included, not only patients
with Medicare Fee-For-Service.
Lower rates are better.
All patients are included, not only patients
with Medicare Fee-For-Service.
Lower rates are better.
All patients are included, not only patients
with Medicare Fee-For-Service.
Lower rates are better.
All patients are included, not only patients
with Medicare Fee-For-Service.
Lower rates are better.
All patients are included, not only patients
with Medicare Fee-For-Service.
Higher rates are better.

ASCQR Specifications Manual
Encounter dates 01-01-25 (1Q25) through 12-31-25 (4Q25) v14.0
CPT® only copyright 2024 American Medical Association. All rights reserved.

Appendix C-1

Appendix C: ASC Measures Quick Reference Guide
Measure
ID
ASC-11

ASC-12

ASC-13

ASC-14

ASC-17

Measure Name
Cataracts: Improvement
in Patient’s Visual
Function Within 90 Days
Following Cataract
Surgery

Facility 7-Day RiskStandardized Hospital
Visit Rate after
Outpatient Colonoscopy
Normothermia

Unplanned Anterior
Vitrectomy

Hospital Visits after
Orthopedic Ambulatory
Surgical Center
Procedures

Measure
Type*
Outcome

Claimsbased
Outcome
Outcome

Outcome

Claimsbased
Outcome

Data Sources
ASC medical records, as well as incident/
occurrence reports, and variance reports are
potential data sources.
Use the CPT® codes indicated in the Specifications
Manual. Data submitted through the Hospital
Quality Reporting (HQR) system at
https://hqr.cms.gov via an online tool available to
authorized users.
Medicare claims and enrollment data.

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 submitted through the
Hospital Quality Reporting (HQR) system at
https://hqr.cms.gov via an online tool available to
authorized users.
ASC medical records, as well as incident/
occurrence reports, and variance reports are
potential data sources.
Use the CPT® codes indicated in the Specifications
Manual. Data submitted through the Hospital
Quality Reporting (HQR) system at
https://hqr.cms.gov via an online tool available to
authorized users.
Medicare claims and enrollment data.

Applicable Notes
All patients are included, not only patients
with Medicare Fee-For-Service.
ASCs have the option to voluntarily submit
data for ASC-11.
Higher rates are better.
Only Medicare Fee-For-Service patients aged
65 years and older.
Lower outcome rates are better.
All patients are included, not only patients
with Medicare Fee-For-Service.
Higher rates are better.

All patients are included, not only patients
with Medicare Fee-For-Service.
Lower rates are better.

Only Medicare Fee-For-Service patients aged
65 years and older.
Lower outcome rates are better.

ASCQR Specifications Manual
Encounter dates 01-01-25 (1Q25) through 12-31-25 (4Q25) v14.0
CPT® only copyright 2024 American Medical Association. All rights reserved.

Appendix C-2

Appendix C: ASC Measures Quick Reference Guide
Measure
ID

Measure Name

ASC-18

Hospital Visits after
Urology Ambulatory
Surgical Center
Procedures
Facility-Level-7-Day
Hospital Visits after
General Surgery
Procedures

Claimsbased
Outcome

Medicare claims and enrollment data.

Claimsbased
Outcome

Medicare claims and enrollment data.

COVID-19 Vaccination
Coverage Among Health
Care Personnel (HCP)

Process

Data Collection Forms and data tracking worksheets
are available on the CDC site at
https://www.cdc.gov/nhsn/ambulatorysurgery/index.html.

ASC-19

ASC-20

Measure
Type*

Data Sources

Applicable Notes
Only Medicare Fee-For-Service patients aged
65 years and older.
Lower outcome rates are better.
Only Medicare Fee-For-Service patients aged
65 years and older.
Lower outcome rates are better.
Sum of Employees (staff on facility payroll),
Licensed independent practitioners:
Physicians, advanced practice nurses,
physician assistants, and adult
students/trainees and volunteers.

*Measure Type – Indicates what is being evaluated by the measure.
• 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.
• Outcome: A measure that indicates the result of performance (or non-performance) of a function(s)
or process(es).

ASCQR Specifications Manual
Encounter dates 01-01-25 (1Q25) through 12-31-25 (4Q25) v14.0
CPT® only copyright 2024 American Medical Association. All rights reserved.

Appendix C-3