Hospital Outpatient Quality Reporting Program Outpatient Hospital & Ambulatory Surgical Center...

Hospital Outpatient Quality Reporting Program

Outpatient Hospital & Ambulatory Surgical Center (ASC) Quality Reporting Requirements:

CY 2012 Outpatient Prospective Payment System (OPPS)/ ASC Proposed Rule with Comment Period

Anita J. Bhatia, PhD, MPHGovernment Task Leader

July 2011

o Clinical Data Submission Deadline August 1, 2011, for Quarter 1 Data

o Monitor your “My QualityNet” accounts to ensure Hospital OQR requirements are met

o Avoid submission of duplicate records

Announcements

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o Data submission deadline is August 15, 2011

o See Specifications Manual for Hospital Outpatient Department Quality Measures v.4.1 for measure information

o To answer these structural measures, “QualityNet Program Management OPPS Structural MSR Update” on My QualityNet is required

o For Security Administrator related issues, contact QualityNet Help Desk 1-866-288-8912

Structural Measure: OP-12

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Outline rule deadlines

Outline policies affecting quality reporting

Outline proposed Hospital OQR & ASC Quality Measures

Provide overview of proposed CY 2012 requirements that affect CYs 2013 to 2016 payment updates

Receive feedback on proposals

Address concerns and answer questions

Objectives

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Proposed Rule Published July 18, 2011http://www.access.gpo.gov/su_docs/fedreg/a110718c.html

Comments due August 31, 2011, 11:59 p.m. ET◦ Electronic

http://www.regulations.gov/#!submitComment;D=CMS-2011-0130-0002

Mail (regular, Express, Overnight)◦ Hand or Courier

Final Rule Scheduled for Display November 1, 2011

Effective with January 1, 2012, services

CY 2012 OPPS/ASC Proposed Rule: Timeline

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Please comment!

Your view from the field is valuable, necessary, and much appreciated!

Will continue to maintain technical specifications in the Hospital OQR Specifications Manual◦ Posted on the http://www.QualityNet.org website◦ Released every 6 months; addenda released as necessary◦ At least 3 months notice for substantial changes and at least 6

months for changes requiring significant system change

Will continue process for retiring measures◦ Immediate, based upon patient safety concerns◦ Otherwise, use of the regular rulemaking process

Finalized Hospital OQR Policies: Technical Specifications Maintenance & Updates

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Data published by CMS Certification Number (CCN)

Multiple campus data combined by CCN

Data made publicly available whether or not validated for payment purposes

Finalized Hospital OQR Policies:Publication on Hospital Compare

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15 measures required for CY 2012 payment 7 chart-abstracted 7 Medicare FFS claims-based 1 structural

8 previously finalized◦ 7 chart-abstracted◦ 1 structural

Total of 23 Quality Measures for CY 2013 Payment Determination

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OP-1 Median Time to Fibrinolysis OP-2 Fibrinolytic Therapy Received Within 30 minutes OP-3 Median Time to Transfer to Another Facility

for Acute Coronary Intervention OP-4 Aspirin at Arrival OP-5 Median Time to ECG OP-6 Timing of Antibiotic Prophylaxis OP-7 Prophylactic Antibiotic Selection for Surgical

Patients

For CY 2013: 7 Chart-abstracted Measures Required for CY 2012 Payment

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OP-8 MRI Lumbar Spine for Low Back Pain OP-9 Mammography Follow-up Rates OP-10 Abdomen CT: Use of Contrast Material OP-11 Thorax CT: Use of Contrast Material

OP-13 Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery

OP-14 Simultaneous Use of Brain Computed Tomography(CT) and Sinus Computed Tomography (CT)

OP-15 Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache

For CY 2013: 7 Claims-based Measures Required for CY 2012 Payment

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Structural Measures◦ OP-12 The Ability for Providers with Health Information

Technology (HIT) to Receive Laboratory Data Electronically Directly into their Qualified/Certified EHR System as Discrete Searchable Data

◦ OP-17 Tracking Clinical Results Between Visits

Claims-based Measures◦ OP-13 Cardiac Imaging for Preoperative Risk Assessment for

Non-Cardiac Low-Risk surgery◦ OP-14 Simultaneous Use of Brain Computed Tomography (CT)

and Sinus Computed Tomography (CT)◦ OP-15 Use of Brain Computed Tomography (CT) in the

Emergency Department for Atraumatic Headache

For CY 2013 Payment: 1 Structural Required for CY 2012 Plus 1 Structural and 3 Claims-based Measures

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OP-16 Troponin Results for Emergency Department AMI or Chest Pain Patients (with Probable Cardiac Chest Pain) Received Within 60 Minutes of Arrival

OP -18 Median Time from ED Arrival to ED Departure for Discharged ED Patients

OP-19 Transition Record with Specified Elements Received by Discharged Patients

OP-20 Door to Diagnostic Evaluation by a Qualified Medical Professional

OP-21 ED – Median Time to Pain Management for Long Bone Fracture

OP-22 ED – Patient Left Without Being Seen OP-23 ED – Head CT Scan Results for Acute Ischemic Stroke or

Hemorrhagic Stroke who Received Head CT Scan Interpretation

For CY 2013 Payment: 7 Additional Chart-Abstracted Measures

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Chart-abstracted measure

Propose that aggregate numerator and denominator counts be entered once per year; no patient-level data

Propose data submission between July 1, 2012 and August 15, 2012

January 1, 2011 thru December 31, 2011 services

Proposed Revision to OP-22 Left Without Being Seen for CY 2013 Payment

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1 NHSN HAI, 6 Chart-Abstracted, 2 Structural Measures OP-24: Surgical Site Infection (NHSN) OP-25: Diabetes: Hemoglobin A1c Management OP-26: Diabetes Measure Pair: A Lipid management: low density

lipoprotein cholesterol (LDL-C) <130, B Lipid management: LDL-C <100 OP-27: Diabetes: Blood Pressure Management OP-28: Diabetes: Eye Exam OP-29: Diabetes: Urine Protein Screening OP-30: Cardiac Rehabilitation Patient Referral From an Outpatient

Setting OP-31: Safe Surgery Checklist Use (Structural) OP-32: Hospital Outpatient Volume Data on Selected Outpatient

Surgical Procedures (Structural)

Proposed Additional 9 Measures for CY 2014 Payment Determination

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OP-24: Surgical Site Infection (NHSN)◦ Submit to CDC’s National Healthcare Safety Network (NHSN)◦ Infection events

Q1 2013 submitted Jan 31st to Aug 1st, 2013 Q2 2013 submitted April 30th to Nov 1st, 2013

Chart-abstracted: OP-25, OP-26, OP-27, OP-28, OP-29, OP-30

Structural (OP-31 & OP-32)◦ Submit data from July 1, 2013 to August 15, 2013◦ For time period from Jan 1, 2012 to December 31, 2012

Proposed Additional 9 Measures for CY 2014 Payment Determination: Data Submission Requirements

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Retain 32 measures for CY 2014

Add NHSN HAI measure: OP-33 Influenza Vaccination Coverage among Healthcare Personnel

Submitted to the NHSN

Infection Events◦ Q1 2013 submitted Jan 31st to Aug 1st, 2013◦ Q2 2013 submitted April 30th to Nov 1st, 2013

Total of 33 measures

Proposed Measures for CY 2015 Payment Determination

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CY 2012 and beyond: Measures descriptions for newly proposed outpatient clinical measures

◦ http://www.hopqdrponline.com/tools.aspx

◦ http://www.qualitynet.org

Proposed CY 2013 payment: Descriptions of 4 additional claims-based imaging efficiency measures

◦ http://imagingmeasures.com/measureset2.html

Measure Descriptions for Newly Proposed Outpatient Measures

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Procedure Specific Measures◦ Colonoscopy & other Endoscopy measures

Cancer Care◦ Adjuvant Chemotherapy is Considered or Administered within 4 months

of Surgery to Patients Under Age 80 with AJCC III Colon Cancer◦ Adjuvant Hormonal Therapy for Patients with Breast Cancer◦ Needle Biopsy to Establish Diagnosis of Cancer Precedes Surgical

Excision/Resection Heart Failure

◦ Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

◦ Left Ventricular Ejection Fraction Assessment◦ Combination Medical Therapy for Left Ventricular Systolic Dysfunction

Measures & Topics Under Consideration for Future Payment Determinations Beginning with CY 2015

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Heart Failure (cont.)◦ Beta-blocker Therapy for Left Ventricular Systolic Dysfunction◦ Counseling Regarding Implantable Cardioverter-Defibrillator (ICD)

Implantation for Patients with Left Ventricular Systolic Dysfunction on Combination Medical Therapy

◦ Symptom Management◦ Symptom and Activity Assessment◦ Patient Education◦ Overuse of Echocardiography◦ Post-Discharge Appointment for Heart Failure Patients

Surgical Safety◦ Patient Fall◦ Patient Burn◦ Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong

Implant◦ Hospital Transfer/Admission

Measures Under Consideration for Future Payment Determinations Beginning with CY 2015

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Patient Experience-of-Care◦ Consumer Assessment of Healthcare Providers and Systems (CAHPS)

surveys for clinicians/groups◦ CAHPS Surgical Care Survey

Anesthesia Related Complications◦ 24 measures

6 additional topics

Measures and Topics Under Consideration for Future Payment Determinations Beginning with CY 2015

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Retaining most procedures from previous years Information submitted using request form on the QualityNet website

◦ Hospital CCN◦ Hospital name◦ CEO, other designated personnel contact information◦ Evidence of impact◦ Date when data submission can resume

CMS will acknowledge receipt and will provide response within 90 days of receipt

NEW – extending to medical record documentation

Proposed Requirements for Hospital Outpatient Quality Reporting: Extraordinary Circumstance Extensions or

Waivers

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Most requirements are the same as implemented last year

Have and Maintain a QualityNet Security Administrator ◦ Security requirement◦ 1 required; recommend having at least 2 for back-up

purposes

Proposed Requirements for Hospital Outpatient Quality Reporting: Administrative

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For the CY 2014 Payment Update: Current participants ◦ 3rd Quarter 2011 through 2nd Quarter 2012 services

Existing Hospitals with Medicare acceptance dates before January 1, 2012◦ Begin data submission with 1st Quarter 2012 services

Hospitals with Medicare acceptance dates after December 31, 2012◦ Begin data submission with 1st full quarter after submitting participation

form

Claims-based measures will be calculated using claims with dates of service for CY 2010

Proposed Requirements for Hospital Outpatient Quality Reporting: Data Collection & Submission

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Sampling & Case Thresholds◦ 5 or fewer for any measure topic: not required to submit, but may do so

voluntarily

Sampling scheme contained in the Specifications Manual

Submission deadlines will be posted on the QualityNet website

Data are to be submitted under the CCN under which the care was furnished

Proposed Requirements for Hospital OQR: Data Collection & Submission

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NEW - Propose that hospitals must submit on a quarterly basis, aggregate population and sample sizes counts for Medicare and non-Medicare encounters for the topic areas for which chart-abstracted data must be submitted

Deadlines for reporting these data would be the same as for chart-abstracted data

We plan to use the aggregate population and sample size data to assess data submission for Medicare and non-Medicare patients

Proposed Requirements for Hospital OQR: Data Collection & Submission

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Retain most procedures from previous years

NEW – Reduce number of randomly selected hospitals to 450

NEW – Sample up to 50 hospitals on proposed targeting criteria

Sample up to 48 cases (12 per quarter) per hospital

Match rate = # measure matches ÷ total # measures

Proposed Requirements for Hospital OQR: Validation

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NEW - Submit documentation to the CDAC within 30 days from the date of request

Letter to be addressed to the hospital’s medical record staff identified by the hospital for submitting inpatient records

Proposed Requirements for Hospital OQR: Validation

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Previously finalized procedures

Would use the upper bound of a one-tailed 95% confidence interval to calculate the validation score

Validation score to be at or above 75%

Would use a binomial approach due to the possibility of small sample sizes

Proposed Requirements for Hospital OQR: Validation

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NEW - Targeting criteria indicating data concerns

◦ Previous validation failure

◦ Extreme outlier values for submitted data elements

NEW - For consideration◦ Not selected for validation in 3 years◦ Low submission numbers relative to population sizes◦ Significant numbers of Unable to Determine values

Proposed Validation Conditions for Hospital OQR: CY 2013 and Possible Considerations

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2% reduction to the annual payment update factor

Any reduction applies only to the payment year involved

As outlined; the application of the reduction results in reduced national unadjusted payment rates that apply to certain items and services provided by hospitals required to report outpatient quality data

Payment Reduction for Hospitals That Fail to Meet Hospital OQR Requirements

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Retaining all procedures from previous year; procedures for validation results and proposing for 2013 and subsequent years

Information submitted using Reconsideration Request form on the QualityNet website

Submit paper copies of any and all medical record documentation that was submitted for the initial validation

Provide a written justification for each appealed data element CMS will acknowledge receipt and will provide response to request

within 90 days of receipt To be able to appeal validation results, must have submitted all

requested documentation in a timely manner

Proposed Reconsideration & Appeals Procedures

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Propose to begin data collection with CY 2012 services

Will affect CY 2014 payment

Seven claims-based measures

Codes (Quality Data Codes) placed on claims

1 HAI measure: Surgical Site Infection

Total of 8 measures

NEW - ASC Quality Reporting Program

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ASC-1 Patient Burn ASC-2 Patient Fall ASC-3 Wrong Site, Wrong Side, Wrong Patient, Wrong

Procedure, Wrong Implant ASC-4 Hospital Transfer/Admission ASC-5 Prophylactic Intravenous (IV) Antibiotic Timing ASC-6 Ambulatory Surgery Patients with Appropriate

Method of Hair Removal ASC-7 Selection of Prophylactic Antibiotic First or

Second Generation Cephalosporin

Proposed ASC Quality Reporting Program: 7 Claims-Based Measures

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ASC-8 Surgical Site Infection

Submitted to the NHSN

CY 2013 Infection Events◦ Q1 2013 submitted Jan 31st to Aug 1st, 2013◦ Q2 2013 submitted April 30th to Nov 1st, 2013

Proposed New National Healthcare Safety Network (NHSN) Healthcare-Associated

Infection (HAI) Measure for the CY 2014 Payment Determination

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Propose for CY 2015 payment determination to retain 8 CY 2014 measures

Adopt 2 Structural Measures◦ ASC-9 Safe Surgery Checklist◦ ASC-10 ASC Volume Data on Selected ASC Surgical

Procedures◦ Data collection July 1, 2013 to August 15, 2013, for CY

2012 services

Total of 10 measures

Proposed ASC Quality Reporting Program: CY 2015 Payment Determination

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Propose to retain measures adopted for CY 2015 payment determination

Add a NHSN HAI measure: ASC-11 Influenza Coverage Among Healthcare Personnel

Total of 11 measures

Proposed ASC Quality Reporting Program: CY 2016 Payment Determination

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Thank you!Anita J. Bhatia, PhD, MPH

anita.bhatia@cms.hhs.gov

Please submit all questions about the Hospital OQR to FMQAI at Hospital Outpatient-Outpatient Questions/Answers or by calling, toll-free, (866) 800-8756 weekdays from 7 a.m. to 6 p.m. Eastern Time.

This material was prepared by FMQAI, the Support Center for the Hospital Outpatient Quality Data Reporting Program (HOP QDRP), under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

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