ASC Quality Reporting: Prepare for the Mandatory OAS CAHPS Measure in 2025

December 23, 2024

Beginning in 2025, the Centers for Medicare and Medicaid Services (CMS) will require the OAS CAHPS Survey measure for ASCQR participants. If you are unfamiliar with this measure, don’t worry! In this blog post, we’ll walk you through what the OAS CAHPS Survey is and how to report it for your ASC.

What Is the OAS CAHPS Survey?

The Outpatient and Ambulatory Surgery (OAS) CAHPS Survey is one of several standardized patient surveys developed through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) program, intended to help providers, payers, and regulators monitor and improve patient experience.

The OAS CAHPS Survey asks patients about:

Preparation for their surgery or procedure,
Check-in and pre-operative processes,
Cleanliness of the surgery facility,
The surgery facility staff,
Discharge from the facility, and
Preparation for recovering at home.

Am I Required to Report OAS CAHPS?

ASCs that are eligible for the OAS CAHPS Survey measure are required to report it in 2025. You are eligible if you meet all of the following criteria in the year prior to the data collection year (i.e., for 2025 reporting, the criteria apply to your ASC in 2024):

You perform procedures within the OAS CAHPS–eligible range of CPT-4 Codes for Surgery (i.e., CPT codes between 10004 and 69990) or G-codes: G0104, G0105, G0121, or G0260;
You are Medicare-certified, have a CMS Certification Number (CCN), and have an agreement with CMS as per 42 CFR 416 Subpart B (General Conditions and Requirements);
You bill under the ASC Payment System when submitting claims to CMS; and
You are eligible to participate in the ASCQR Program.

Are There Any Exceptions?

If you are eligible for the OAS CAHPS Survey measure but provided care to fewer than 60 OAS CAHPS Survey-eligible patients between January 1 and December 31 of the year prior to the data collection year, you can apply for an exemption through the OAS CAHPS website. You must submit the exemption request by December 31 of the data collection year.

For example, if you provided care to fewer than 60 eligible patients in 2024, you can apply for an exemption for 2025 by submitting a request by December 31, 2025.

Important Note: The exception is not determined based on how many patients were surveyed in 2024; it is determined based on how many patients were eligible to be surveyed in 2024. The OAS CAHPS website will help you calculate this number.

If you are exempt from the ASCQR program, you are also exempt from the OAS CAHPS Survey. There is no need to apply for a separate exemption.

How Do I Report OAS CAHPS?

You cannot administer the OAS CAHPS Survey yourself. You must select a CMS-approved survey vendor to conduct the survey monthly and submit your data before each quarterly deadline. The registration process, outlined below, includes completing an authorization form for your chosen vendor.

Select your vendor from this list of approved survey vendors.

Steps to Register

Complete this form on the OAS CAHPS website to register for login credentials.
Once you have your credentials, log in to your OAS CAHPS account. You should be able to see your customized dashboard.
From your dashboard, complete the Facility CCN Registration form.
From your dashboard, complete the online authorization form to authorize an approved survey vendor to facilitate the OAS CAHPS Survey and submit the data on your behalf.

For more detailed registration instructions and answers to frequently asked questions, consult the OAS CAHPS FAQ Guide.

What Are My Responsibilities After Registering?

You are responsible for providing your vendor with a monthly patient information file, which includes a complete and accurate list of patients and relevant data. The Survey Materials page on the OAS CAHPS website includes a template you can use for this file. Ensure that patient data is encrypted and that you use a secure method to send it to the vendor.

You’ll also have to work with your vendor to establish the date they will submit your data to the OAS CAHPS Data Center. Data can be reported monthly or quarterly but must be submitted by the quarterly deadline (listed in the “Important Dates and Deadlines” section below).

It’s your responsibility to monitor data submission reports to ensure the vendor has submitted the data correctly and hasn’t encountered any issues.

Important Dates and Deadlines

Although there isn’t a formal deadline for registering and authorizing your vendor, you’ll have to complete this by early 2025 in order to meet monthly data collection requirements.

According to OAS CAHPS guidelines, the survey should be initiated 21 days after the sample month ends, with the latest initiation date being one month plus 14 days after the sample month ends. This means that for the sample month of January 2025, the last day to initiate the survey is March 14, 2025. To ensure adequate time for compiling the patient information file, allowing the vendor to review it, and meeting sampling requirements, you should start the process well before this date.

Survey data must be collected over a period of 6 weeks. The vendor can submit the survey data either as it is collected for each month or by the quarterly deadline.

The data submission deadlines for 2025 are:

Quarter	Deadline
2025 Quarter 1	July 9, 2025
2025 Quarter 2	October 8, 2025
2025 Quarter 3	January 14, 2026
2025 Quarter 4	April 8, 2026

Can I Communicate with My Patients about the OAS CAHPS Survey?

You are allowed to inform patients that they may be selected for the OAS CAHPS Survey, but you cannot influence their responses in any way.

The following actions are prohibited:

Providing a copy of the OAS CAHPS Survey questionnaire, cover letters, or invitation letters/email messages to patients,
Asking any OAS CAHPS-related questions before or after the survey is administered,
Including survey language verbatim in marketing or promotional materials,
Telling patients you hope they will give you the best rating or respond in a particular way to the survey questions,
Implying that staff will be rewarded for positive feedback,
Offering incentives for participating (or not participating) in the survey,
Helping patients answer survey questions (even if they ask for help), and
Inquiring about why a patient gave a specific response or rating on any survey question.

For a complete overview of your responsibilities and guidelines for appropriate and inappropriate actions, refer to the OAS CAHPS Protocols and Guidelines Manual.

What Happens if I Don’t Report OAS CAHPS?

Starting in 2025, the OAS CAHPS measure will be linked to reimbursement. If you are eligible for the survey and do not qualify for an exemption, you must report the OAS CAHPS measure. Failure to do so will result in a -2% penalty in your annual fee schedule update.

Next Steps

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Written By: Sarrah Hakim, MHSA