Surgery Measure (OP-36)

Reports

For Calendar Year (CY) 2020 Payment Determination

Prior to final measure calculation and public reporting in January 2020 for CY 2020 payment determination, the Centers for Medicare & Medicaid Services (CMS) will provide facilities with:

  • Two Claims Detail Reports (CDRs)
    To be released in September 2018 (with data on surgeries performed from January 1 – May 31, 2018) and March 2019 (with data on surgeries performed from January 1 – November 30, 2018); and
  • One Facility-Specific Report (FSR)
    To be released in October 2019 and based on data from CY 2018.

Claims Detail Reports (CDRs)

The CDR is an Excel file that includes patient-level data for the Surgery measure, but does not include any measure calculations. CDRs provide facilities with an opportunity to improve the quality of care provided to patients receiving outpatient surgeries prior to final measure calculation and public reporting of measure results.

For those who do not receive a CDR, CMS is providing a mock CDR containing simulated facility specific data. The documents and their descriptions are included below:

  • OP-36 Surgery Mock CDR, XLS-101 KB (04/08/19) – A sample surgery CDR containing mock patient-level data. This report serves as an example of the CDRs participating Hospital Outpatient Departments (HOPDs) will receive prior to the final measure calculation and public reporting of measure results.
  • Surgery Measure CDR User Guide, PDF-410 KB (04/08/19) – An overview of measure methodology, instructions for interpreting the CDR, and links to additional resources.

Facility Specific Report (FSR)

The FSR is an Excel file that measure performance results, state and national results, detailed patient-level data used to calculate measure results, and a summary of each facility’s case mix.

For those who do not receive an FSR, CMS is providing a mock FSR containing simulated facility specific data. The documents and their descriptions are included below.

  • OP-36 Surgery Mock FSR (January 1, 2018 through December 31, 2018 data) – A sample Surgery FSR containing mock patient- and state-level data and actual national results. This report serves as an example of the FSRs participating HOPDs will receive prior to the public reporting of measure results. The mock FSR will be available prior to the FSR release in October 2019.
  • Surgery Measure FSR User Guide – An overview of measure methodology, instructions for interpreting the FSR, and links to additional resources. The FSR User Guide will be available prior to the FSR release in October 2019.

See question #15 in the Frequently Asked Questions document for reasons a facility might not receive a CDR.

Questions and Comments

Please submit questions about the outpatient Surgery measure to the Outpatient Question and Answer tool. To ensure proper handling of inquiries, please reference the hospital’s CMS Certification Number (CCN). Do NOT email your CDR or FSR nor submit patient-identifiable information (e.g., Date of Birth, Social Security Number, Health Insurance Claim Number, dates, procedure codes) to this address. Sending screenshots and/or describing a patient listed in your FSR is considered Protected Health Information (PHI).

QualityNet requires Internet Explorer with JavaScript enabled on it.

Steps to enable JavaScript in Internet Explorer
  1. Click on the Tools menu option at the top of the page.
  2. Select Internet Options from the drop-down menu.
  3. From the dialog box, choose the Security tab.
  4. Click on Custom Level.
  5. Set Active Scripting to Enable.
  6. Click OK to close the custom settings dialog.
  7. Click OK to close the Options dialog.