On November 1, 2024 the Centers for Medicare and Medicaid Services (CMS) released the 1,734-page 2025 Ambulatory Surgical Center Quality Reporting Program (ASCQR) Final Rule. This blog post breaks down the final changes to the ASCQR.
2025 Final Changes: 3 New Measures
Facility Commitment to Health Equity (FCHE) Measure
- Will 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.
Source: CMS’s Attestation Guide for Commitment to Health Equity Measure
- 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”.
Screening for Social Drivers of Health (SDOH) Measure
- Will be voluntary for 2025 and mandatory for 2026.
- This measure is an ASC version of MIPS measure 486 (Screening for SDOH) and will require screening for the five Health-Related Social Needs (HRSN) – food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.
- Screening for this measure can be done using any screening tool that addresses these 5 HRSN. For example:
The Accountable Health Communities Health-Related Social Needs Screening Tool
- Additional tools, including comprehensive information and comparison, can be found on the Social Interventions Research and Evaluation Network (SIREN) website.
- 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) Measure*
- Will be voluntary for 2025 and mandatory for 2026.
- This measure will 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.
Final 2025 ASCQR Measure Set
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Written By: **Jessica Peterson, MD, MPH
About the Author: Jessica Peterson, MD, MPH is the Senior Director of Value-Based Care Policy at Anatomy IT.