Quality Reporting for Your ASC: 2025 Proposed Changes

On July 10, 2024 the Centers for Medicare and Medicaid Services (CMS) released the 984-page 2025 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.

2025 Proposed Changes: 3 New Proposed Measures

Facility Commitment to Health Equity (FCHE) Proposed Measure

  • Proposed to 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 (PDF).

  • 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)

Screening for Social Drivers of Health (SDOH) Proposed Measure

  • Proposed to be voluntary for 2025 and mandatory for 2026.
  • This proposed measure is an ASC version of MIPS measure 486 (Screening for SDOH) and would require screening for the five Health-Related Social Needs (HRSN) – food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.
  • Screening for this proposed measure could be done using any screening tool that addresses these 5 HRSN. For example:
  • 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) Proposed Measure

  • Proposed to be voluntary for 2025 and mandatory for 2026.
  • This proposed measure would 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.

Proposed 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 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)
*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

Requests for Comment on Potential Future Changes

CMS included one 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.

Potential Future Specialty Focused Reporting for the ASCQR Program

CMS is considering implementing a specialty-focused quality reporting approach for ASCs. Specifically, CMS is requesting comment on a couple of approaches under consideration:

  • The “Specialty-Select” Framework
    • Non-claims-based measures: ASCs would be required to select a specified number of the remaining non-claims-based specialty-specific measures to report, if those measures are applicable to that ASC. The required number would be determined in future rulemaking.
    • Claims-based measures: Would require reporting on all specialty-specific claims-based measures because “these measures are not administratively burdensome to ASCs.”
  • Alternative: Specialty Threshold Framework
    • Non-claims-based measures: ASCs would be required to report all non-claims-based specialty-specific measures for which the ASC’s case counts reach a specified case minimum. The case minimum would be determined in future rulemaking.
    • Claims-based measures: Would also require reporting on all specialty-specific claims-based measures because “these measures are not administratively burdensome to ASCs.”

Both of these approaches would create quality measure reporting requirements that are more aligned with the procedures performed at an individual ASC. These frameworks treat claims-based measures the same (required), but the treatment of the non-claims-based specialty-specific measures could vary significantly.

For the Specialty Threshold Framework, it is not clear from the description when the case count for each measure would be calculated. It is possible that ASCs would not know definitively which measures they would be required to report on until after the end of the reporting period.

Alternatively, for the Specialty-Select Framework, it is not clear what would occur should an ASC not have sufficient germane measures to meet the number that would be specified in future rulemaking.

Next Steps

  • Share this information with your colleagues.
  • Subscribe to our newsletter to get alerts on this and other important issues. You can subscribe using the field in our website footer below.
  • 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!


Jessica Peterson, MD, MPHWritten By: Jessica Peterson, MD, MPH

About the Author: Jessica Peterson, MD, MPH is the Senior Director of Value-Based Care Policy at Anatomy IT.