Quality Reporting for Your ASC: 2025 Final Changes
On November 1, 2024 the Centers for Medicare and Medicaid Services (CMS) released the 1,734-page 2025 Ambulatory Surgical Center Quality Reporting Program (ASCQR) Final Rule. This blog post breaks down the final changes to the ASCQR.
2025 Final Changes: 3 New Measures
Facility Commitment to Health Equity (FCHE) Measure
- Will be mandatory beginning with the 2025 reporting period/2027 payment determination period.
- This measure is based on the existing Hospital Commitment to Health Equity (HCHE) measure and will measure an ASC’s commitment using 5 equity-focused organizational domains, each of which has multiple elements.
Source: CMS’s Attestation Guide for Commitment to Health Equity Measure
- Measure Scoring: This is a 5-part attestation-based measure (1 attestation for each domain)
- Numerator: The total number of domains to which the ASC is able to attest “yes” (up to a maximum of 5)
- In order to attest “yes” for a domain, you must be able to attest “yes” to all elements within that domain.
- If you cannot attest “yes” to any element within a domain, then, for that domain, you must attest “no”.
- Denominator: 5 points (1 point for each domain)
- Numerator: The total number of domains to which the ASC is able to attest “yes” (up to a maximum of 5)
Screening for Social Drivers of Health (SDOH) Measure
- Will be voluntary for 2025 and mandatory for 2026.
- This measure is an ASC version of MIPS measure 486 (Screening for SDOH) and will require screening for the five Health-Related Social Needs (HRSN) – food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.
- Screening for this measure can be done using any screening tool that addresses these 5 HRSN. For example:
- The Accountable Health Communities Health-Related Social Needs Screening Tool
- Additional tools, including comprehensive information and comparison, can be found on the Social Interventions Research and Evaluation Network (SIREN) website.
- Measure Scoring: Calculated as a performance rate.
- Numerator: Number of patients admitted to an ASC who are 18+ years old on the date of admission and are screened for all 5 HRSNs.
- Denominator: Number of patients admitted to an ASC who are 18+ years old.
- Exclusions for Patients Who: 1. Opt-out of screening, or 2. Are themselves unable to complete the screening and have no legal guardian or caregiver able to do so on the patient’s behalf.
Screen Positive Rate for Social Drivers of Health (SDOH) Measure
- Will be voluntary for 2025 and mandatory for 2026.
- This measure will evaluate the rates of patients who screened positive for each HRSN, using the same tool used in the Screening for SDOH measure.
- Measure Scoring: Calculated as a performance rate [5 separate rates – 1 for each HRSN]
- Numerator: Number of patients receiving care at an ASC who are 18+ years old on the date of admission, are screened for all 5 HRSNs, and who screen positive for having a need in the HRSN being evaluated [5 separate rates – 1 for each HRSN].
- Denominator: Number of patients admitted to an ASC who are 18+ years old and are screened for all 5 HRSNs during their care.
- Exclusions for Patients Who: 1. Opt-out of screening, or 2. Are themselves unable to complete the screening and have no legal guardian or caregiver able to do so on the patient’s behalf.
Final 2025 ASCQR Measure Set
| ASC # | Measure Name | Mandatory/Voluntary |
| ASC-1 | Patient Burn | Mandatory |
| ASC-2 | Patient Fall | Mandatory |
| ASC-3 | Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant | Mandatory |
| ASC-4 | All-Cause Hospital Transfer/Admission | Mandatory |
| ASC-9 | Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | Mandatory |
| ASC-11 | Cataracts Visual Function (Previously referred to as Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery) | Voluntary |
| ASC-12 | Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy | Mandatory |
| ASC-13 | Normothermia Outcome | Mandatory |
| ASC-14 | Unplanned Anterior Vitrectomy | Mandatory |
| ASC-15a-e | OAS CAHPS Measures | Mandatory |
| ASC-17 | Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures | Mandatory |
| ASC-18 | Hospital Visits after Urology Ambulatory Surgical Center Procedures | Mandatory |
| ASC-19 | Facility-Level 7-Day Hospital Visits after General Surgery Procedures Performed at Ambulatory Surgical Centers | Mandatory |
| ASC-20 | COVID-19 Vaccination Coverage Among Health Care Personnel | Mandatory |
| ASC-21 | Risk-Standardized Patient-Reported Outcome-Based Performance Measure (PRO– PM) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) in the ASC Setting (THA/TKA PRO–PM) | Voluntary (Mandatory starting in 2028) |
| *New* | Screening for Social Drivers of Health (SDOH) | Voluntary (Mandatory starting in 2026) |
| *New* | Screen Positive for Social Drivers of Health (SDOH) | Voluntary (Mandatory starting in 2026) |
| *New* | Facility Commitment to Health Equity (FCHE) | Mandatory |
Next Steps
- Share this information with your colleagues.
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- If you are an Anatomy IT client:
- Contact your ASCQR Expert if you have any questions or if you plan on adding a new facility.
- If you are not an Anatomy IT client:
- Contact us to learn more about our services and to reap the rewards of our combined decades of experience.
Written By: Jessica Peterson, MD, MPH
About the Author: Jessica Peterson, MD, MPH is the Senior Director of Value-Based Care Policy at Anatomy IT.
