Any ASC that did not meet the program requirements for quality reporting will be subject to an ASCFS 2% payment reduction for their services provided to Medicare beneficiaries. This applies to Railroad Medicare, Primary Medicare and as of Jan. 1, 2013 Medicare Secondary beneficiaries. The payment reduction effects only the ASCFS, not the ASCDRUG file, ASCPI file code assignments or the ASC Code Pair file.
For example, a service with a $100 allowed amount would produce a provider payment of $78.40 and a patient responsibility of $19.60 for a total of $98.00. A $2.00 loss in revenue per $100 in service rendered.
The adjustment codes found on the Medicare remittance advices that will be applied to reflect the reductions are:
Claim Adjustment Reason Code (CARC) 237 – Legislated/Regulatory penalty. (This will be accompanied by a remark code.)
Remittance Advice Remark Code (RARC) N551 – Payment adjusted based on the Ambulatory Surgical Center (ASC) Quality Reporting Program.
Evaluation
of ASC reporting compliance affecting payments for CY 2014 will be
performed based upon claims data processed by the MAC by April 30, 2013 covering dates of service Oct. 1, 2012 to Dec. 31, 2012.ASCs report their Claims Based Measures with Quality Data Codes (QDCs) on Medicare Part B HCFA-1500 or in electronically formatted claims. The claims will be analyzed at the supplier level and tied to the billing NPI.
The 5 QDC’s listed below used for ASC reporting during the third quarter of 2012 are also required for reporting period January 1, 2013 – December 31, 2013. Claims Based Measures reported for service dates in 2013 will count towards meeting requirements for the CY2015 ASCFS.
ASC Quality Measures G-code Descriptor ASC PI
ASC – 1through 4 G8907 Patient documented not to have M5
experienced any of the following events:
a burn prior to discharge, a fall within the
facility, wrong site/side/patient/procedure/
implant event,a hospital transfer or hospital admission upon discharge from the facility.
ASC
– 1 Patient burn G8908 Patient documented to
have received a burn M5
prior to discharge.
ASC – 1 Patient burn G8909 Patient documented not to have received a M5
burn prior to discharge.M5
ASC
– 2 Patient fall in G8910 Patient documented to
have experienced a fall M5
ASC facility within ASC facility.
ASC – 2 Patient fall in G8911 Patient documented not to have experienced M5
ASC facility a fall within ASC facility.
ASC – 3 Wrong site, G8912 Patient documented to have experienced a M5
wrong side, wrong patient, wrong site, wrong side, wrong patient, wrong
wrong procedure, procedure or wrong implant event.
wrong implant
ASC – 3 Wrong site, G8913 Patient documented to not have experienced M5
wrong side, wrong patient, a wrong site, wrong side, wrong patient, wrong
wrong procedure, procedure or wrong implant event.
wrong implant
ASC
– 4 Hospital G8914 Patient documented
to have experienced a M5
transfer/Admission hospital transfer or hospital admission upon
discharge from ASC.
ASC – 4 Hospital G8915 Patient documented to not have experienced M5
transfer/Admission hospital transfer or hospital admission upon
discharge from ASC.
ASC
– 5 Timing of G8916 Patient with
preoperative order for IV M5
Prophylactic Antibiotic antibiotic surgical site infection
administration for
SSI prevention (SSI) prophylaxis, antibiotic initiated on time
ASC
– 5 Timing of G8917 Patient with
preoperative order for IV M5
Prophylactic Antibiotic antibiotic surgical site infection
administration for
SSI prevention (SSI) prophylaxis, antibiotic not initiated on time
ASC
– 5 Timing of G8918 Patient without
preoperative order for IV M5
Prophylactic Antibiotic antibiotic surgical site infection
administration for
SSI prevention
 Need help to remember to add your Charge Based Measures?
With Iridium Suite Practice Management System from Medical Business Systems, a custom claim scrubber
rule can be created for your practice. This would alert the user that
additional codes should be entered when a “qualifying” service is being
charged to Medicare.
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Annual data submission period for these measures wasJuly 1, 2013 – August 15, 2013 covering the performance period January 1, 2012- December 31, 2012.
ASC – 6: Measure ascertains response to the following question(s):
• Does/did your facility use a safe surgery checklist based on accepted standards of practice during the designated period? Yes/No
ASC – 7: Measure ascertains response to the following question(s):
• What was the aggregate count of selected surgical procedures per category?
There are eight categories: Cardiovascular, Eye, Gastrointestinal, Genitourinary, Musculoskeletal, Nervous System, Respiratory, and Skin each with designated HCPCS for measurement. For more details, access the Specifications Manual.
| Need help to remember to submit your Structural Measures?
With Iridium Suite Practice Management System from Medical Business Systems, a CPT Code report template
can be created and scheduled to generate automatically when needed.
The report should show up in your email inbox with all the data required
for reporting to QualityNet.
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If
you are notified that you are subject to this reduction, but believe it
is an error, you can ask for a reconsideration of the claim reporting
review. You would submit a CMS Reconsideration Request form by March 17th of the payment year.If CMS determines the reduction penalty was an error, they will notify the MAC to remove the penalty for future claims processing and instruct them to reprocess all previously processed claims containing the incorrect reduced payment amount.
The remittance advice containing claims that have been reprocessed with the corrected allowed amount will indicate this correction with Remittance Advice Remark Code (RARC) N552 – Payment adjusted to reverse a previous withhold amount.
Unfortunately,
you cannot turn back time if you did not comply with the previous
reporting requirements, but you should do everything possible now to
“get with the program” and begin reporting the applicable measures to
your local Medicare contractor.
Additional helpful information can be found at:http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/index.html
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ASC-Quality-Reporting/
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