Regulatory Reporting Requirements for ASCs: The ASCQR Program
Ambulatory Surgery Centers (ASCs) have revolutionized outpatient care by offering a convenient and high-quality alternative to hospitals. These facilities specialize in same-day surgical care, including diagnostic and preventive procedures, without requiring overnight stays. As more than half of surgeries now take place in outpatient settings, ASCs have become a cost-effective and essential part of the healthcare system.
Beyond delivering high-quality patient care, ASCs must navigate complex legal and regulatory requirements. ASCs that treat Medicare beneficiaries must comply with the Ambulatory Surgical Center Quality Reporting (ASCQR) Program to avoid a reduction to future Medicare reimbursements. Here is what ASCs need to know about the ASCQR Program.
What Is The ASCQR Program?
Authorized by the Medicare Improvement and Extension Act-Tax Relief and Health Care Act of 2006, the ASCQR Program is a pay-for-reporting initiative that collects and publicly reports quality measure data from ASCs paid under the ASC fee schedule. It was developed to enhance the quality of care in ASCs. The program requires ASCs to report data on specific quality measures, including infection rates, patient outcomes, and complication rates.
ASCs must comply with the program to maintain eligibility for Medicare reimbursements. Centers that fail to meet reporting requirements will face payment reductions. Most ASCs treat Medicare beneficiaries, requiring them to comply with Medicare’s standards for patient care, billing, facility operations, and quality reporting. Under the program, ASCs must meet all reporting requirements or face a 2-percentage point payment penalty on their annual payment rate update.
What Is Required of ASCs?
The ASCQR can be difficult to navigate. To provide some context, on November 1, 2024, the CMS released the 1,734–page 2025 ASCQR Final Rule.
In 2025, the ASCQR Program includes 14 mandatory measures that facilities must report on to avoid reductions in future Medicare reimbursements. Of these, 10 measures require ASCs to take action in 2025.
The following quality measures are mandatory under the ASCQR Program for 2025:
ASC-1: Patient Burn
ASCs must report any patient burn incidents to ensure that care facilities are monitoring and preventing preventable injuries.
ASC-2: Patient Fall
Reporting falls that occur within the ASC setting is required to track patient safety and improve fall prevention strategies.
ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant
ASCs must report any instances of procedural errors, such as performing surgery on the wrong patient, site, or side, to ensure patient safety and quality control.
ASC-4: All-Cause Hospital Transfer/Admission
This measure requires ASCs to report any cases where patients are transferred or admitted to a hospital after their procedures, as part of tracking post-operative care and outcomes.
ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
ASCs must report on the follow-up care interval for colonoscopies performed on average-risk patients, to ensure that patients receive appropriate surveillance and preventive care.
ASC-12: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy
ASCs must report the risk-standardized hospital visit rate within seven days of an outpatient colonoscopy to track complications and ensure patient safety after procedures.
ASC-13: Normothermia Outcome
Reporting on normothermia, or maintaining a patient’s normal body temperature during surgery, is mandatory to ensure patient safety and reduce the risk of complications.
ASC-14: Unplanned Anterior Vitrectomy
ASCs must report any unplanned anterior vitrectomies performed during eye surgeries to monitor procedural complications and improve surgical outcomes.
ASC-15a-e: OAS CAHPS Measures
ASCs are required to report patient experience data through the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, ensuring the collection of patient feedback on care quality.
ASC-17: Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures
Reporting on hospital visits following orthopedic surgeries is mandatory to assess post-operative care and minimize complications in orthopedic procedures performed in ASCs.
ASC-18: Hospital Visits after Urology Ambulatory Surgical Center Procedures
ASCs must report any hospital visits following urology surgeries to track patient outcomes and the effectiveness of urology procedures performed in the outpatient setting.
ASC-19: Facility-Level 7-Day Hospital Visits after General Surgery Procedures Performed at Ambulatory Surgical Centers
Reporting hospital visits within seven days after general surgery procedures is required to monitor post-operative care and identify any complications or issues.
ASC-20: COVID-19 Vaccination Coverage Among Health Care Personnel
ASCs must report the vaccination coverage of their healthcare personnel against COVID-19 to ensure workforce safety and reduce the risk of healthcare-associated transmission.
New for 2025: Facility Commitment to Health Equity (FCHE)
ASCs must report their commitment to health equity. This measure aims to promote inclusivity and reduce disparities in healthcare access and outcomes.
There are also voluntary reporting requirements that will become mandatory in future years.
How Is The Data Collected, And Where Does It Go?
The ASCQR Program collects and analyzes quality measures to evaluate how effectively Ambulatory Surgical Centers (ASCs) provide care and adhere to best practices that promote optimal patient outcomes. These measures transform patient data into quantifiable metrics that assess and compare the quality of care across different facilities. The data is collected through a variety of methods, including chart abstraction, claims data, patient surveys, and web-based entries, focusing on key aspects such as patient outcomes, safety, and care coordination.
This information is made publicly available on the data.cms.gov website, allowing consumers and healthcare professionals to compare the quality of care across various healthcare settings, including ASCs and hospital outpatient departments. By promoting transparency, the ASCQR Program encourages healthcare providers to enhance their care quality. It also offers benchmarks for selected clinical areas, fostering continuous improvement and helping facilities align with industry standards to achieve the best possible patient care.
Contact an Experienced Healthcare Attorney
Given the strict regulations governing ASCs and the importance of the ASCQR Program in maintaining Medicare reimbursement eligibility, working with experienced healthcare attorneys is essential. With their healthcare law expertise, ASCs can stay compliant with both federal and state regulations, minimizing the risk of payment reductions and potential legal issues, while focusing on delivering high-quality care to patients.