As you are our valued partner, we are pleased to help you stay informed about the regulatory program changes surrounding the Centers for Medicare & Medicaid Services’ (CMS) Ambulatory Surgical Center Quality Reporting (ASCQR) Program for 2025 dates of service. The measure details can be found here.
A brief review of each ASCQR measure, from the ASC application standpoint, is provided below. Please note:
- Measure questions, along with general Q&A, should be directed to QualityNet.
- If you have questions from the gGastro®/ModMed® ASC application standpoint, please reach out to gSupport@modmed.com.
| Measure Number | Measure Details | How to Capture the Data | Other Details |
| ASC-1 | Patient Burn During ASC Encounter | ASC Quality Codes template section, displayed by default on the ASC Quality Form, but can be placed on any template within the service. | Reports → ASC-1 Patient Burn |
| ASC-2 | Patient Fall During ASC Encounter | ASC Quality Codes template section, displayed by default on the ASC Quality Form, but can be placed on any template within the service. | Reports → ASC-2 Patient Fall |
| ASC-3 | Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure or Wrong Implant | ASC Quality Codes template section, displayed by default on the ASC Quality Form, but can be placed on any template within the service. | Reports → ASC-3 Wrong Side, Wrong Patient, Wrong Procedure or Wrong Implant |
| ASC-4 | All-Cause Hospital Transfer/Admission | ASC Quality Codes template section, displayed by default on the ASC Quality Form, but can be placed on any template within the service. | Reports → ASC-4 All-Cause Hospital Transfer/Admission |
| ASC-9 | Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | Screening Indication = Z12.11
Normal Findings with no interventions Plan: 10-Year Colonoscopy Recall |
Reports → ASC-09 Follow-Up Interval for Average Risk Patients |
| ASC-11 | Cataracts: Improvements in Patient’s Visual Function within 90 Days Following Cataract Surgery | Voluntary Measure | Report → N/A |
| ASC-12 | Facility 7-Day Risk Standardization Hospital Visit Rate after Colonoscopy | Automatically calculated via claims; no data submission necessary. | |
| ASC-13 | Normothermia Outcome |
|
Report → ASC-13 Normothermia Report |
| ASC-14 | Unplanned Anterior Vitrectomy | CPT Code = 66984, 66982 or 66983
Complication Type = Anterior Vitrectomy with or without Mechanical Assistance |
Report → ASC-14 Unplanned Anterior Vitrectomy Report |
| ASC-15 | Outpatient Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey | Configurations/CAHPS Export | ASCs must use an approved OAS CAHPS Survey vendor and pre-register via the OAS CAHPS website. More information is available on ASCA’s OAS CAHPS Survey page.
CMS vendor submits on facility behalf. |
| ASC-17 | Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures | Automatically calculated via claims; no data submission necessary. | Hospital visits within seven days of the orthopedic procedure |
| ASC-18 | Hospital Visits after Urology Ambulatory Surgical Center Procedures | Automatically calculated via claims; no data submission necessary. | Hospital visits within seven days of the urology procedure |
| ASC-19 | Facility-Level 7-Day Hospital Visits after General Surgery Procedures Performed at Ambulatory Surgical Centers | Automatically calculated via claims; no data submission necessary. | Hospital visits within seven days of the general procedure |
| ASC-20 | COVID-19 Vaccination Coverage Among Healthcare Personnel | ASCs must collect the number of healthcare personnel (HCP) who have received a completed COVID-19 vaccination course (numerator) and the total number of HCP eligible to work in the ASC for at least one day during the reporting period (denominator); and submit to the NHSN HPS Component for at least one self-selected week each month. | Reports → N/A |
| 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 for 2025 DOS | Reports → N/A |
| ASC-22 | Screening for Social Drivers of Health (SDOH) | Scoring and reporting will be incorporated in 2025 to meet the deadline of 2026 DOS. Voluntary for 2025 DOS. | Coming in 2025 for 2026 DOS |
| ASC-23 | Screen Positive for Social Drivers of Health (SDOH) | Scoring and reporting will be incorporated in 2025 to meet the deadline of 2026 DOS. Voluntary for 2025 DOS. | Coming in 2025 for 2026 DOS |
| ASC-24 | Facility Commitment to Health Equity (FCHE) | Reporting requires Demographics and/OR Social Determinants of Health Calculations. Attestation is yes/no. | Report → N/A |
Should you have any questions regarding this matter, please contact our Support Team.