Medicare ASC Quality Reporting Program

In 2025, there are 14 mandatory measures in the ASC Quality Reporting (ASCQR) Program on which facilities must report to avoid a reduction to future Medicare reimbursements. 10 measures require action to be taken by ASCs in 2025.

The data for 8 measures will be submitted through the Centers for Medicare & Medicaid Services (CMS) Hospital Quality Reporting (HQR) secure portal. The COVID-19 Vaccination Coverage Among Health Care Personnel (HCP) measure (ASC-20) is submitted through the National Healthcare Safety Network (NHSN) Healthcare Personal Safety (HPS) Component.

2025 Measures

Click on the heading tabs below to find out more information.

ASC-1: Patient Burn

  • Submitted via: HQR Secure Portal
  • Due date: May 15, 2026
  • Additional Notes: Data for this measure must be collected for all patients, not just fee-for-service Medicare beneficiaries.

ASC-2: Patient Fall

  • Submitted via: HQR Secure Portal
  • Due date: May 15, 2026
  • Additional Notes: Data for this measure must be collected for all patients, not just fee-for-service Medicare beneficiaries.

ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant

  • Submitted via: HQR Secure Portal
  • Due date: May 15, 2026
  • Additional Notes: Data for this measure must be collected for all patients, not just fee-for-service Medicare beneficiaries.

ASC-4: All-Cause Hospital Transfer Admission

  • Submitted via: HQR Secure Portal
  • Due date: May 15, 2026
  • Additional Notes: Data for this measure must be collected for all patients, not just fee-for-service Medicare beneficiaries.

ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients

  • Submitted via: HQR Secure Portal
  • Due date: May 15, 2026

  • Additional Notes: ASCs are only required to collect information on a “sample of eligible patients with minimal case number requirements.”

    If your center does not perform colonoscopies, select the box under the measure name and description that states: “Please enter zeros for this measure as I have no data to submit.”

ASC-11: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery [Voluntary Measure]

  • Submitted via: HQR Secure Portal
  • Due date: May 15, 2026
  • Additional Notes: Voluntary measure, not endorsed by CMS Consensus-Based Entity (CBE)

ASC-12: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy

  • Submitted via: Automatically calculated via claims, no data submission necessary
  • Due date: N/A
  • Additional Notes:

ASC-13: Normothermia Outcome

  • Submitted via: HQR Secure Portal
  • Due date: May 15, 2026

  • Additional Notes: This measure is used to assess the percentage of patients having surgical procedures under general or neuraxial anesthesia of 60 minutes or more in duration who are normothermic within 15 minutes of arrival in PACU.

    If your center does not perform procedures related to this measure, select the box under the measure name and description that states: “Please enter zeros for this measure as I have no data to submit.”

ASC-14: Unplanned Anterior Vitrectomy

  • Submitted via: HQR Secure Portal
  • Due date: May 15, 2026
  • Additional Notes: If your center does not perform procedures related to this measure, select the box under the measure name and description that states: “Please enter zeros for this measure as I have no data to submit.”

ASC-15 a–e: Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey

ASC-17: Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures

  • Submitted via: Automatically calculated via claims, no data submission necessary
  • Due date: N/A
  • Additional Notes: Hospital visits within seven days of the orthopedic procedure

ASC-18: Hospital Visits after Urology Ambulatory Surgical Center Procedures

  • Submitted via: Automatically calculated via claims, no data submission necessary
  • Due date: N/A
  • Additional Notes: 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

  • Submitted via: Automatically calculated via claims, no data submission necessary
  • Due date: N/A
  • Additional Notes: Hospital visits within seven days of the general surgery procedure

ASC-20: COVID-19 Vaccination Coverage Among Health Care Personnel

  • Measure Information Form: NHSN COVID-19 Vaccination Coverage among Healthcare Personnel
  • Submitted via: National Healthcare Safety Network (NHSN) Healthcare Personnel Safety (HPS) Component
  • Due date: Data must be submitted quarterly according to the following schedule
    Quarterly Data Submission Deadline
    2024 Q3 Data (July 1–September 30, 2024) February 15, 2025
    2024 Q4 Data (October 1–December 31, 2024) May 15, 2025
    2025 Q1 Data (January 1–March 31, 2025) August 15, 2025
    2025 Q2 Data (April 1–June 30, 2025) November 15, 2025
  • Additional Notes: 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.

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 Measure]

  • Submitted via:
  • Due date: May 15, 2026
  • Additional Notes: Mandatory reporting beginning with the CY 2028 reporting period/CY 2031 payment determination

Facility Commitment to Health Equity (FCHE)

  • Submitted via: HQR Secure Portal
  • Due date: May 15, 2026

  • Additional Notes: This is a pay-for-reporting measure, simply completing the FCHE questionnaire will fulfill the measure. The questionnaire score will not affect reimbursement.

    More information is available on the QualityNet site, including the measure specifications as well as attestation guidance.

Screening for Social Drivers of Health (SDOH) [Voluntary Measure]

  • Submitted via: HQR Secure Portal
  • Due date: May 15, 2026
  • Additional Notes: Mandatory beginning with CY 2026 data collection/CY 2028 payment determination

Screen Positive for Social Drivers of Health (SDOH) [Voluntary Measure]

  • Submitted via: HQR Secure Portal
  • Due date: May 15, 2026
  • Additional Notes: Mandatory beginning with CY 2026 data collection/CY 2028 payment determination

Important Reminders

To report ASC-1, ASC-2, ASC-3, ASC-4, ASC-9, ASC-13, ASC-14 and the Facility Commitment to Health Equity (FCHE) measure via the Hospital Quality Reporting (HQR) secure portal as required, your ASC must first register a Security Official on that site. Registration instructions can be found on the QualityNet site. (Tip: Allow plenty of time for this process.) It is recommended that each facility have two or more Security Officials. Once registered, the Security Officials(s) will need to log in at least every 60 days to ensure the account remains active. More information is also available in a 2021 ASC Focus Digital Debut piece on HARP enrollment.

If you need assistance, please call the QualityNet Help Desk at 866.288.8912 or contact ASCQR Program Support through the Quality Question and Answer Tool.