Quality Reporting for Your ASC: 2026 Proposed Changes

July 17, 2025

This week, the Centers for Medicare and Medicaid Services (CMS) released the 913-page 2026 Ambulatory Surgical Center Quality Reporting Program (ASCQR) Proposed Rule. This blog post breaks down the proposed changes to the ASCQR and requests for feedback.

Anatomy IT will be submitting comments on this proposed rule and we encourage you to as well. In the coming weeks, we will publish a guide on how you can submit your comments to CMS.

2026 Proposed Changes: 4 Measure Removals and 1 New Measure

Proposed 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.

Proposed New Measure

Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery (Information Transfer PRO-PM)

Proposed to be voluntary for 2027-2028 and mandatory beginning with the 2029 reporting period.
This is a Patient Reported Outcome-Based Performance Measure (PRO-PM) that would use a 9-item survey to assess patient understanding of provided discharge information for patients age 18+ who had a procedure (surgical or non-surgical) at an ASC.
- The survey evaluates patient understanding of information across three domains: applicability to patient needs, medication, and daily activities.

A copy of the survey is available on page 20 of Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, PRO-PM (PDF).

If finalized, ASCs would have the option of either distributing the survey and collecting the data themselves or through an authorized third-party vendor (can use the same vendor they use for the OAS CAHPS survey).
CMS proposes to require the survey to be distributed 2-7 days after post-op through either e-mail or text. Patients would have a 65-day window to respond.

Measure Scoring: Calculated by adding the individual scores from eligible respondents and dividing this by the total number of respondents.
- Numerator: The sum of the individual scores received by the ASC from eligible respondents (patients or caregivers).
  - The individual score for each respondent is calculated by taking the total number of items for which the respondent gave the most positive response (“Yes” or “Very Clear”) and dividing this by number of items applicable to their surgery (items with any response other than “Does not apply”).
- Denominator: The total number of patients age 18+ who had a procedure or surgery in an ASC and responded to the survey.
- Only fully completed surveys are included in the measure calculation.

Proposed 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	Voluntary
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)

Proposed Update to Extraordinary Circumstance Exception (ECE)

CMS proposes to update 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 has directly impacted the facility's ability to meet a quality data reporting requirement, or
An extraordinary circumstance has impacted an entire region or locale.

Requests for Comment on Potential Future Changes

CMS included a significant request for comment in this proposed rule. This represents changes under consideration for proposal in a future rule. Comments submitted to CMS on this topic have the potential to impact a future proposed change as it is in development.

Measure Concepts Under Consideration for Future Years: Well-Being and Nutrition

CMS is requesting feedback on potential well-being and nutrition measures for inclusion in future rulemaking. Areas of particular interest include:

Tools and measures that evaluate overall health, happiness, and life satisfaction, including aspects such as emotional well-being, social connections, sense of purpose, and personal fulfillment.
The applicability of tools and frameworks that assess the integration of complementary and integrative health, skill-building, and self-care strategies.
Tools and measures focused on optimal nutrition and preventive care.
- CMS specifies that nutritional assessments may involve strategies, guidelines, and practices aimed at promoting healthy eating habits and ensuring individuals receive the nutrients needed for health, growth, and overall well-being.
- Additionally, CMS highlights that such assessments could also include aspects of health that influence nutritional status, such as physical activity or sleep.

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.

If you have any questions on this, let us know!

Written By: Sarrah Hakim, MHSA