1. ASC Quality & Structural Measures
Starts October 1, 2012

2. The Quality 5 Measures

3. Although not required by CMS, GSC should track the Quality Measures on all admissions.
At some point, all payers will likely adopt the measures in an effort to enforce penalties for non compliance.
A pt’s insurance info can change the same day of a procedure. Therefore picking and choosing select pts based on insurance criteria is not recommended.

4. What Does CMS define as an Admission?
ASC Admission
Completion of registration upon entry into the facility.
An admission to GSC is the time between the pts arrival and Pre-op Start time.
An Admission time MUST be entered. Vision tracks an ASC Admission based on the presence of this information.
NO ADMISION TIME = NO ADMISION = NOT REPORTED BUT STILL SUBJECT TO AUDIT

5. Many ASC have been using Quality Measures since the beginning of 2012.
As Such, Vision did not integrate the CPT codes associated with the Measures.
All Measure and Coding links have been created by the GSC staff and at this time everything has been linked.

6. What does linking mean?
CPT code integration based on an information the clinical staff populates in the EHR.
If the Information is not populated, the codes will not generate
Generation is needed in order to report the codes to CMS and be in compliance.

8. A “Yes” or “No” selection Must be Made for all 4 Measures

9. Patient Burn
Unintended tissue injury caused by any of the 6 recognized mechanisms
1. Scalds
2. Contact
3. Fire
4. Chemical
5. Electrical
6. Radiation

10. Pt Burn Reporting Clinical
Reported in EHR based on the check box for Yes or No.
Billing
G8908 Pt Received a burn prior to discharge
G8909 Pt Did Not Receive a Burn
G8907 Bundle code – none of the 4 measures occurred before discharge.

11. Patient Fall
A sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls from violent blows or other purposeful actions.

12. PT Fall reporting Clinical Reported in the Check Box Billing
G8910 Pt fell prior to discharge
G8911 Pt Did Not Fall
G8907 Bundle code – none of the 4 measures occurred before discharge

13. Wrong Site/Side/Pt/Procedure/Implant
Not in accordance with the intended
Site
Side
Patient
Procedure
Implant

14. Reported in the Check Box
Reporting
Clinical
Reported in the Check Box
Billing
G8912 It Occurred
G8911 Did not Occur
G8907 Bundle code – none of the 4 measures occurred before discharge

15. Hospital Transfer/Admission
Any transfer/admission from the ASC directly to an acute care hospital or emergency room.
At all times, a selection must be made as to how the pt was discharged.
ALL patients should have a discharge time since ALL pts are admitted into GSC.
No Discharge time after 23 hours represents a NON-Ambulatory even which and ASC is not allowed.

17. Reported in the Check Box
Reporting
Clinical
Reported in the Check Box
Reported on PACU Page
Both must Match!
Please note that if for example the Quality Measure Checklist has a check of “no” but the discharge status states that the pt was admitted to a hospital, this will represent a conflict…as it should. Something must be corrected. Either the pt was released normally and the proper discharge drop down should be picked or, the pt was admitted and the check box should be checked as “yes”.
Billing
G8914 It Occurred
G8915 Did not Occur
G8907 Bundle code – none of the 4 measures occurred before discharge

18. Prophylactic IV Antibiotic Timing
Antibiotic Administered on time.
- infusion is initiated within one hour of the incision, introduction of endoscope, inflation of tourniquet or 2 hours prior if using vancomycin or fluoroquinolones.
Intravenous
- Administration of a drug within a vein including Bolus, Infusion, IV piggyback.

19. Prophylactic IV Antibiotic Timing
Order
A written order, Verbal order, standing order or standing protocol
Prophylactic Antibiotic
- Prescribed for the INTENT of reducing the probability of an infection related to an invasive procedure

20. Reporting of IV Prophylactic Antibiotic Timing
What is reported.
- If the Prophylactic is on the list
- If its to prevent and SSI Infection
- If its administered via IV
MUST MEET ALL 3

21. How Reported Clinical Anesthesia Page 1
If you do not see it in the drop down please let us know. We must make sure its on the list of approved Prophylactics
Vision will Assume a quantity if 1. This can be changed in the resources section like any other resource
If its for SSI Prevention then Click the box. If not, then it should not have been listed as it does not meet the reporting standard

22. Continued
2 Hour- Click this box ONLY if you administered a regulated IV Prophylactic antibiotic like Vancomycin or fluoroquinolones. Keep this in mind as picking this option will make vision assume that there should a certain amount on time between administering the antibiotic and the incision start time.
Start Time - The Administered time of the Prophylactic was at least 1 full minute before the incision start time and should not exceed 61 min.
The End time is not required. But feel free to use it if needed for documentation.

23. What is Time Compliant
Ex. Doctor ordered the use of Prophylactic IV Antibiotic of Ampicillin.
It was administered at 3:30pm. The surgeon then proceeded with the incision at 3:31pm. Since the incision was at least 1 min after the start of the Prophylactic, the CMS considered it ON TIME.

24. What is Not Time Compliant
Ex. Surgeon orders Ampicillin for Prophylactic Antibiotic via IV for SSI prevention
The Ampicillin is administered at 3:30 pm. The incision does not start until 4:50pm. Since it has been more than 61 min, the use of the Prophylactic was Not Compliant.
Note that if using a 2 hour Antibiotic then that administration time must me between 1 min and 121 minutes.

25. How Reported Billing G8916 – Antibiotic imitated on time.
G8917 – Not on time
G8918 – No order of IV Prophylactic
Currently there is no dedicated area to state that a IV Prophylactic was not ordered by the physician when he/she was asked. It is customary to administer but not mandatory. It can be documented on Chart.

28. Structural Measures 2 Parts - Safe Surgery Checklist
Will be reported in 2013 but includes data from January 2012 to December 2012
2 Parts
- Safe Surgery Checklist
- Procedural Volume Reporting

29. Safe Surgery Checklist
Facility must have a safe surgery checklist in place for all surgical cases in 2012 (ALL)
This report will print in vision and then must be entered into the QualityNet website (not yet up) in Similar to SPARKS. Only 1 user allowed.
Use Surgery Checklist in Vision’s EHR, 2 pages. The questions asked on the checklist in Vision are the ones needed for the reporting.

31. PG1 Continued

32. Page 2

33. PG 2 Continued

34. Facility Volume Reporting
Know as the “6th” Measure
All Procedure are categorized by system, category and procedure code
The goal of this measure is so that CMS tracks what the case loads are for an ASC.

37. Internal Reports to keep track of Quality Reporting
Quality Data Collection Report
Report prints from Vision’s Report section.
Used for the tracking all 5 measures.
Can be filtered for only Medicare case reporting.
Report read as a Numerator/ Denominator representation

38. Internal Reports to keep track of Quality Reporting
For IV prophylactic Antibiotic Measure (Measure 5)
Denominator = all ASC Admissions (admit time must be present) with an order for IV prophylactic Antibiotic. Any case where an IV Prophylactic Antibiotic is picked from the drop down menu (WHICH SHOULD ONLY BE ENTERED IF IT MEETS THE CRITERIA).
Numerator = All ASC Admission where the IV Prophylactic was done on time (Compliant).
Ex.(15/20)
15 cases where the IV prophylactic Antibiotic for SSI prevention was done on time
20 All Cases where the IV prophylactic Antibiotic for SSI prevention was used.
75% Compliant

40. Internal Reports to keep track of Quality Reporting
All other 4 Measures
Numerator = Occurred Event
Denominator = All ASC ADMISSIONS
Ex. 1/20 =
1 cases where the pt fell
20 All Cases performed

41. Quality Tracking report
Detailed information about all 5 quality measures for All cases.

42. Understanding the necessity of documented time entry
Because of the Quality Control Collection measures that will begin on October 1, 2012, Missing time in EHR will create errors that can directly impact how CMS sees the Compliancy GSC.
Those who report information to CMS cannot assume that something did or did not happen.
Maybe the IV prophylactic was administered over 61 minutes before the incision. May it was performed on time but the entry time was not entered into the appropriate area. Only those who are present and responsible for the Quality measure used for the safety of the pt can indicate said information in the EHR

43. How Time Entry Is Evaluated Per CMS Definitions
Times must follow a logical order.
i.e. a pts cannot be timed as discharged before they have arrived.
A pt cannot have preop time marked as ended before its begun.
If the pts arrives, then the pt must leave.
Human Error account for most time discrepancies.

44. Arrival
Time at which the pt enters through the doors of the facility and is “arrived” by the front desk.
Entered in only by the front desk

45. Admit Time Completion of registration upon entry into the facility.
Currently linked to the Pre-Op Start Time in the Pre-Op tab
May be unlinked as to comply with definition (at a later time)

46. Sched Start & End
Time booked by “Booking” as the expected start and end time for a procedure or visit.

47. PreOp Start
Time at which the pt enters the pre-operative room where vital will be taken
Clinical parties introduce themselves
Consent is obtained
Evaluation for surgical competency and health assessment is initialized.
Located in the Pre-Op tab

48. PreOp End Time at which the initial Evaluation ends.
If the pt is ready and fit for the procedure, then the pt will now be escorted to the appropriate procedure of OR room.
Located in the Pre-Op Tab.
Preop Start and End must be at least 1 min apart.

49. Intra Op Start Time at which the pt is brought into the room.
The primary component of the visit
For Pre Admission Testing, this is the time the physician or Physician Assistant, begins the medical exam. Consultation start time begins here.
Located in the IntraOp Tab

50. Intra Op End Time the pt leaves the procedure room.
For Medical Clearance Visits (PAT), the time the physician or PA ends the documentation and evaluation of the patient. The PAT Time used for billing and reporting thus must correspond to the Intra-op start and Intra-Op end.
Located in the IntraOp Tab
IntraOp Start and End must be at least 1 min apart.

51. Inc./Procedure Start Time at which the Procedure/Surg starts.
The primary component of the visit
Located in the IntraOp Tab

52. Inc/Proc End Time the surgery ends (before the pts is wheeled out)
Located in the IntraOp Tab
IntraOp Start and End must be at least 1 min apart.

53. Anes Start Time at which the administration of Anesthesia is performed
Can be started before or after intra-op start time (procedure).
Located in the Anesthesia tab

54. Anes End Time Time at which the administration of anesthesia ends.
If there is an Anes Start time, then there must be an End time.
The Anes Start and End must be in logical order and at least 1 min apart.
i.e. Start of Anesthesia at 3:55 and the End of Anesthesia at 3:56.

55. Pacu 1 Start Post-anesthesia care unit
Time when the monitoring of the pt after the pt has been wheeled out of the OR and into a designated care area begins.
Located in the Pacu 1 tab

56. PACU End
Time at which the pt’s monitoring after the procedure has ended.
Currently linked to Discharge time but may change.
PACU start and end Must be at least 1 minute apart.

57. Discharge Time
Time at which a patients leaves the care of the facility.
Currently linked to PACU End or IntraOp End with the description of the pt was admitted to a hospital or it was a routine discharge but this may change
If the change occurs, the Front Desk will enter in the Discharge time once the patient leaves the center.
All pts must be discharged not matter if the visit was for a procedure or medical visit.