Quality Reporting for Your ASC: 2027 Proposed Changes

This morning, the Centers for Medicare and Medicaid Services (CMS) released the 723-page 2027 Ambulatory Surgical Center Quality Reporting Program (ASCQR) Proposed Rule. This blog breaks down the proposed ASCQR changes and requests for feedback.

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

2027 Proposed Changes: 1 Measure Removal

The Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients measure is proposed for removal, beginning in 2027.

CMS’ rationale for removing this measure is that it assesses documentation of a 10-year interval for a follow-up colonoscopy, rather than a patient outcome. Because there is already an ASCQR measure that evaluates whether patients return to the hospital within 7 days of a colonoscopy (Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy), CMS feels that the Follow-Up Interval measure is unnecessary.

There are no other proposed measure changes to the ASCQR Program for 2027, and no new measures are being proposed for addition.

Proposed 2027 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-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 2029)

 

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.

Stratification of the All-Cause Transfer/Admission Measure

CMS is requesting feedback on potentially changing the All-Cause Transfer/Admission measure to incorporate phases of care (e.g., pre-op, intra-op, and post-op).

Currently, this measure assesses the overall rate of patients receiving care in an ASC who require a hospital transfer or admission. It does not look at when the need for transfer/admission occurs.

CMS feels that differentiating between phases of care would provide further insights and more comprehensive information to monitor patient safety. For example, a hospital transfer/admission occurring prior to the procedure could indicate the effectiveness of pre-op evaluation of patients. Additional examples of potential areas associated with each phase of care are listed below.

Areas Associated with Pre-op

• Pre-op evaluation
• Patient selection
• Escalation or transfer processes

Areas Associated with Intra- and Post-op

• Anesthesia administration
• Procedure itself
• Recovery
• Complications

CMS would like feedback on feasible and meaningful approaches for incorporating phases of care into the All-Cause Transfer/Admission measure. Specific areas of interest include:

• A framework for stratification
• Time windows to define each phase of care
• Operational definitions of these phases