Medicare ASC Quality Reporting Toolkit

The GI societies have received many questions on whether your ambulatory surgical center (ASC) is required to participate in the Medicare ASC Quality Reporting Program. Please find below some clarification questions to help determine whether your facility is expected to report quality measures on a CMS-1500 payment claims form.

What is the definition of an ambulatory surgery center (ASC)?

• According to the Medicare Claims Processing Manual, Chapter 14, an ASC is a distinct entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients.¹ The ASC must have in effect an agreement with CMS to participate in Medicare.

An ASC is either free-standing/independent (i.e., not a part of a provider of services or any other facility), or operated by a hospital (i.e., under the common ownership, licensure or control of a hospital). A hospital-operated facility has the option of being considered by Medicare either to be an ASC or to be a provider-based department of the hospital as defined in 42 CFR 413.65.²

If a facility meets CMS requirements to participate as an ASC, it bills the Medicare contractor on Form CMS-1500 or the related electronic data set and is paid the ASC payment amount.

• Please note that the facility may also submit a separate CMS-1500 form for the providers’ professional fee. (Medicare ASC Quality Reporting measures are reported on the CMS-1500 form for the facility fee reimbursement.)
• Please note that a free-standing facility may submit claims to private insurers using a UB-04 payment claim. However, if the ASC is a free-standing facility participating in Medicare, the ASC submits claims to Medicare using this CMS Form 1500 in order to receive Medicare facility fee reimbursement.

If the facility submits claims to Medicare using a UB-04 claims form, then please check with your administrators as your facility may not be a free-standing or independent facility.³ If your facility is hospital-owned, then your facility would not participate in the ASC Quality Reporting Program, and instead, participate in the Medicare Hospital Outpatient Quality Reporting (OQR) Program.

Related Questions:

Our off-site ambulatory surgical area is not licensed by the state as a distinct entity. The Medicare patients are billed using the ASC billing process. If not licensed as an ASC, does this exclude all the cases from the ASC indicators?

• If the facility is billing Medicare for ASC fee-for-service reimbursements, then the facility will be affected by the requirements and payment effects of the ASC Quality Reporting Program.

I would like clarification on the definition of an “Ambulatory Surgical Center (ASC)” as it relates to the requirements for the ASC Quality Reporting Program. Are only free-standing ASCs that are billing with their own CMS Certification Number (CCN) included?

• You are correct. ASCs have their own ASC numbers (the third digit is the letter “C”) and bill using their own payment-claims system.
• An ASC that is part of a hospital’s regional outpatient facility that is billing under the hospital’s CCN would not be included and therefore not required to participate in the Medicare ASC Quality Reporting program, but instead, Medicare’s quality reporting program for outpatient hospitals. The ambulatory surgery cases billed under the hospital’s CCN would be eligible for inclusion in the relevant measures in the Medicare Hospital Outpatient Quality Reporting (OQR) Program.

Please click here to access the slides from the October 1, 2012 tri-society webinar. (pdf)

Click here to view the slides from the June 4, 2012 tri-society webinar. (pdf)

Click below to watch the webinar. (webinar begins on slide number 5)