ASCQR CY 2025 Supporting Statement Part B (final rule)

Supporting Statement - Part B

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

Collection of Information Employing Statistical Methods

1. Describe potential respondent universe.

All ASCs receiving reimbursement under the Outpatient Prospective Payment System (OPPS) having 240 or more reimbursed Medicare claims (primary and secondary payer) in an applicable payment determination year in the United States; approximately 4,200 facilities.

2. Describe procedures for collecting information.

Data have been collected from quality data codes (QDCs) entered on Medicare non-institutional claims via the CMS-1500 form, via on-line submission directly to CMS through a secure portal to CMS’ Hospital Quality Reporting (HQR) system.

Data may be patient-level, summary, or aggregate data submitted directly to CMS via a secure web portal or the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) by either the facility or their authorized vendor(s), as specified.

3. Describe methods to maximize response rates.

To maximize response rates, the ASCQR Program provides payment consequences related to participation requirements. Specifically, ASCs that do not meet program requirements will receive a 2.0 percentage point reduction to their annual payment increase provided under the revised ASC payment system for a given CY. In addition, CMS provides abstraction and submission tools, education and outreach, technical assistance for ASCs requiring assistance with program requirements.

To reduce burden and thereby maximize response rates, ASCs can sample for measures that require direct data entry (i.e., Endoscopy/Polyp Surveillance, Cataract Visual Function, and Normothermia Outcome). Sample size requirements per year per ASC for these measures is based on an ASC’s denominator population for a measure. ASCs can utilize sampling techniques of their choosing.

4. Describe any tests of procedures or methods.

(b) Sampling for Chart-Abstracted Data for the ASCQR Program

To reduce burden, ASCs may submit samples of their case populations for some ASCQR Program measures dependent of the case population size. For populations of less than 63 all cases are required; for a population size of between 63 and 900, 63 cases are required; and a population size of greater than 900, 96 cases are required, though ASCs can submit more cases than the minimum if they so choose. ASCs that choose to sample should ensure that the sampled data represents their ASC population by using either the simple random sampling or systematic random sampling method and that the sampling techniques are applied consistently within a quarter. For example, quarterly samples for a sampling population should use consistent sampling techniques across the quarterly submission period. ASCs may also submit measure data for the entire applicable patient population in lieu of sampling.

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

Anita Bhatia, PhD, MPH Grace Snyder, JD, MPH

410-786-7236 410-786-0700