Quality Reporting: Demystifying the ASC Quality Reporting Program

How to submit 2025 data to safeguard payment rates and avoid penalties.

The Center for Medicare & Medicaid Services’ Ambulatory Surgery Center Quality Reporting Program (ASCQR) is complex, even for experienced professionals in ASC leadership roles. For new administrators, navigating these reporting requirements can be overwhelming. Whether you’re a veteran leader or new to your position, here’s how to get a handle on your center’s quality data and prepare your ASCQR submission.

What is the ASCQR program?

This CMS pay-for-reporting, quality data program requires participating ASCs to report quality-of-care data for standardized measures in order to receive the full annual update to their ASC annual payment rate. ASCs that do not meet the reporting requirements incur a 2.0 percentage-point reduction to any payment update provided under the revised ASC payment system for that year.

ASCs in the program must report if they filed more than 240 Medicare claims (primary plus secondary payor) during a reporting period per year. For example, ASCs with fewer than 240 Medicare claims in 2023 are not required to submit data from last year that would determine next year’s payment rates.

Another source of confusion for ASC leaders is the requirement to report on procedures that aren’t performed at their facilities. For example, the ASC-14 measure, Unplanned Anterior Vitrectomy, is specific to eye surgery. Unfortunately, reporting on this measure is still required even for ASCs that don’t perform these procedures. If your ASC has no data to submit for a particular measure, then an attestation must be completed, or zeros must be submitted. Any measure that is left blank (excluding voluntary measures) will result in your ASC not meeting the ASCQR Program requirements for the applicable payment determination year and subsequently face a 2.0 percentage-point reduction.

Deadlines and details

The deadline to submit ASCQR data for patient encounters from 2024 is May 15. There are eight Quality Reporting Web-Based Measures, a voluntary survey measure, a National Healthcare Safety Network (NHSN) measure and four claims-based measures.

Facilities are responsible for reporting the web-based measures and the NHSN measure. The claim-based measures data are calculated from paid Medicare fee-for-service claims, so no additional data submissions are required by facilities.

Reporting is required for the following Web-Based Measures: ASC-1, Patient Burn; ASC-2, Patient Fall; ASC-3, Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant; ASC-4, All-Cause Hospital Transfer/Admission; ASC-9, Endoscopy/Poly Surveillance … Appropriate Follow Up Interval for Normal Colonoscopy in Average Risk Patients; ASC-11, Cataracts - Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery (voluntary); ASC-13, Normothermia; ASC-14, Unplanned Anterior Vitrectomy; ASC-15a-e, Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare providers and Systems (voluntary); and ASC-20, COVID-19 Vaccination Coverage Among Healthcare Personnel.

Where to start?

There are two unique registrations needed for submitting the required data. Each registration requires completing the specified identify proofing process, which may take two to four weeks to complete. First, register for a Health Care Quality Information Systems (HCQIS) Access Roles and Profile (HARP) account. This includes designating a security official (SO) for reporting. Next, register for a Secure Access Management Services (SAMS) account for data entry in the CDC’s NHSN system. You will need to designate a facility administrator (FA) for reporting. You must log in to the HCQIS and NHSN systems at least every 60 days to keep the accounts active. If you do not have a SO or FA, you should initiate this process immediately to meet the reporting deadlines.

ASCs submit most measure data via the HQR system, an online tool available to authorized users. Log into the HQR system and follow all steps. Remember, data fields are required and cannot be left blank, so enter zeros for any measure for which you have no data. Each measure is submitted individually and will display a message saying “All Measures Successfully Submitted” when the process is complete.

NHSN web-based submissions

The COVID-19 Vaccination Coverage Among HCP measure is currently the only measure in the ASCQR Program that requires submission via the web-based NHSN system. ASCs must report data for one self-selected week each month that ends in the month intended for reporting. To submit the data: Log into the NHSN system; enter your SAMS credential; select the NHSN reporting option; select “Healthcare Personnel Safety” in the dropdown menu; select your ASC; and select “vaccination summary.”

Navigating the ASCQR is complex, but it’s manageable. By being informed about the reporting measures, you’ll contribute to the ongoing improvement of healthcare quality, and you’ll avoid penalties by hitting CMS’ deadlines.

Need help navigating your ASC Quality Reporting requirements? ASC Academy: A Guide to Quality & Risk Management offers the guidance and turnkey tools you need to make it a breeze. Learn more at aorn.us/quality-and-risk-guide. OSM