Quality Reporting for Your ASC: 2026 Final Changes
On November 21, 2025, the Centers for Medicare and Medicaid Services (CMS) released the 1,657-page 2026 Ambulatory Surgical Center Quality Reporting (ASCQR) Program Final Rule. This blog post breaks down the final changes to the ASCQR program.
2026 Final Changes: 4 Measure Removals
Measure Removals
- Beginning with the 2024 performance year:
- COVID–19 Vaccination Coverage Among Health Care Personnel (HCP)
- Beginning with the 2025 performance year:
- Facility Commitment to Health Equity (FCHE)
- Screening for Social Drivers of Health (SDOH)
- Screen Positive Rate for SDOH
CMS’ removal rationale for these measures is that the costs associated with achieving a high score on the measure outweigh the benefit of its continued use in the program.
No New Measures
Although CMS proposed 1 new survey measure [Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery (Information Transfer PRO-PM)], this measure was not finalized.
In making this decision, CMS considered public comments, which raised concerns including low response rates and survey fatigue among patients.
If you are interested in what the proposed measure entailed, refer to our previous blog on the proposed changes.
Final 2026 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-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) |
Update to Extraordinary Circumstance Exception (ECE)
CMS has updated the ASCQR ECE policy to clarify that CMS has the discretion to grant an extension for an ECE request.
Additionally, CMS may grant an ECE to one or more facilities that have not submitted an ECE request if CMS determines that:
- A systemic issue with a CMS data collection system directly impacted the facility’s ability to meet a quality data reporting requirement, or
- An extraordinary circumstance impacted an entire region or locale.
While CMS proposed to allow ASCs only 30 days to submit the ECE request from the date of the extraordinary circumstance (as opposed to 90 days, which is the current deadline), CMS took comments into consideration and finalized that ASCs will have 60 days from the date of the circumstance to submit the ECE.
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.
- If you are not an Anatomy IT client, contact us to learn more about our MIPS Success Plan and to reap the rewards of our combined decades of experience.
If you have any questions on this, let us know!
Written By: Sarrah Hakim, MHSA
About the Author: Sarrah is the Director of Health Policy at Anatomy IT.
