Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs; Overall Hospital Quality Star Rating; Hospital Price Transparency; and Notice of Closure of a Teaching Hospital and Opportunity To Apply for Available Slots

Section 1861(kkk)(7)(C)(i) of the Act generally provides that any measure specified by the Secretary for use in the REHQR Program be endorsed by the entity with a contract under section 1890(a) of the Act, also known as the consensus-based entity (CBE).

The Emergency Care Access & Timeliness eCQM was submitted to the CBE for endorsement review in the Fall 2024 cycle (CBE #4625e), and the CBE endorsed the measure for use in the REHQR Program with conditions on February 12, 2025.\381\ The conditions include that the measure developer explore: (1) the unintended consequences to patients and providers by engaging with the patient community and accountable entities; and (2) the data elements to identify and address where challenges may persist. If our proposal to adopt the Emergency Care Access & Timeliness eCQM is finalized, CMS would closely monitor the effects of this measure in REHs and data as part of the standard measure maintenance (90 FR 33771).

\381\ Partnership for Quality Measurement. (2025). Fall 2024 Cycle Endorsement and Maintenance (E&M) Technical Report. Available at https://p4qm.org/sites/default/files/Initial%20Recognition%20and%20Management/material/EM-Fall-2024-Initial-Recognition-Final-Project-Report.pdf. Accessed: April 30, 2025.

We believe this measure is appropriate for measuring quality of care under the REHQR Program because ED care is the primary focus of REHs. Furthermore, we believe that this measure meets the selection criteria under section 1861(kkk)(7)(C)(i) of the Act because it is endorsed by the CBE.

The REHQR Program's statute also includes a requirement at section 1861(kkk)(7)(C)(iii) of the Act to consider ways to account for rural emergency hospitals that lack sufficient case volumes when selecting measures to ensure that the performance rates for such measures are reliable. We note that the target population for this measure is comprised of patients of all ages, for all payers, that visit an REH during a 1-year measurement period. As such, we anticipate that the overall number of patients that visit an REH within a given year would be high enough so that there would not be any issues with low case volumes that could undermine the reliability of this measure when used in the REH context. We therefore do not believe the Emergency Care Access & Timeliness eCQM would suffer from low case volumes, and we further believe that we have appropriately considered low case volumes as required by the REHQR statute when selecting this measure. f. Data Collection, Submission, and Reporting

The Emergency Care Access & Timeliness eCQM is specified in a standard electronic format, utilizing data extracted electronically from EHRs, with all data coming from defined fields in electronic sources. We note that eCQMs allowing for the retrieval of data directly from the EHR will minimize errors due to manual abstraction of data.\382\ As discussed in the CY 2026 OPPS/ASC proposed rule (90 FR 33771 and 33772), we proposed that REHs would be required to report either the Emergency Care Access & Timeliness eCQM or the Median Time for Discharged Patients measure. We refer readers to the CY 2026 OPPS/ ASC proposed rule (90 FR 33774 through 33776) for a discussion of proposed eCQM form, manner, and timing of data submission and reporting requirements. If an REH chooses to report the Emergency Care Access & Timeliness eCQM, the REH would report the data using the proposed methods and standards specified in section XVI.C.2. of this final rule with comment period.

\382\ Centers for Medicare & Medicaid Services. (2023). Electronic Clinical Quality Measures (eCQMs) Specification, Testing, Standards, Tools, and Community. Available at https://mmshub.cms.gov/sites/default/files/eCQM-Specifications-Testing-Standards-Tools-Community.pdf. Accessed: April 30, 2025.

In the CY 2026 OPPS/ASC proposed rule (90 FR 33772), we proposed to adopt the Emergency Care Access & Timeliness eCQM into the REHQR Program measure set beginning with the CY 2027 reporting period/CY 2029 program determination. However, as discussed later in the CY 2026 OPPS/ ASC proposed rule (90 FR 33775 and 33776), we also proposed that the Emergency Care Access & Timeliness eCQM would not be a required measure under the REHQR Program, and that REHs could thus elect to report either the Emergency Care Access & Timeliness eCQM or the Median Time for Discharged ED Patients measure for a given reporting period/program determination. We stated that providing REHs with the option to report either of these measures would provide greater flexibility for REHs to implement EHR infrastructure that meets their individual needs while still prioritizing measurement of the variation in access to and the timeliness of emergency care, the goal of promoting interoperability, and reducing burden for REHs in the long term. We note that adoption of this measure does not change the number of mandatory quality measures required to be reported in the REHQR measure set.

The Median Time for Discharged ED Patients measure assesses the time patients spent in the ED before being sent home, also known as ED throughput. We note that this measure is reported quarterly, compared to the Emergency Care Access & Timeliness eCQM, which is less burdensome as it is reported annually. We further emphasize that the Emergency Care Access & Timeliness eCQM measures four different ED metric components in a single measure and is more comprehensive than the Median Time for Discharged ED Patients measure which measures one ED metric component.\383\ Additionally, the eCQM measures transfer boarding time in the ED and time from arrival to placement in a treatment room, which are not currently captured by the Median Time for Discharged ED Patients measure, or

any other measure currently in the REHQR Program measure set.\384\

\383\ The Median Time for Discharged ED Patients was adopted in the REHQR Program in the CY 2024 OPPS/ASC final rule with comment period (88 FR 49832).

\384\ Partnership for Quality Measurement (n.d.). Emergency Care Capacity and Quality. Available at https://p4qm.org/measures/4625e. Accessed: April 30, 2025.

We refer readers to section XV.B.1. of this final rule with comment period where we finalize adoption of a similar version of this eCQM for the Hospital Outpatient Quality Reporting Program. With that finalized adoption, we note that adoption of this eCQM in the REHQR Program would also provide greater alignment of metrics between the two quality reporting programs.

We refer readers to the CY 2024 OPPS/ASC final rule with comment period (88 FR 49832) for more information on the Median Time for Discharged ED Patients measure.\385\

\385\ Partnership for Quality Measurement. Median Time from ED Arrival to ED Departure for Discharged ED Patients. Available at https://p4qm.org/measures/0496. Accessed: April 30, 2025.

We intend to publicly report data submitted on the Emergency Care Access & Timeliness eCQM and the Median Time for Discharged ED Patients measure on a CMS website after a 30-day preview period. Public reporting for both measure serves to provide similar data on timeliness and encourages REHs to implement process improvements and reduce inefficiencies in ED operations, resulting in better quality of care.

We invited public comment on our proposal to adopt the Emergency Care Access & Timeliness eCQM as an optional measure beginning with the CY 2027 reporting period/CY 2029 program determination.

We note that we are finalizing the adoption of the Emergency Care Access & Timeliness eCQM in the Hospital OQR Program in section XV.B.1. of this final rule with comment period. We refer readers to that section for general comments related to the Emergency Care Access & Timeliness eCQM.

We invited public comments on our proposal.

Comment: Many commenters supported our proposal to adopt the Emergency Care Access & Timeliness eCQM as proposed. A few commenters supported the measure as appropriate and relevant to the REH setting, noting that ED care is a primary focus of REHs and that the measure appropriately addresses the growing challenges of ED occupancy and boarding, challenges which directly affect patient safety and timeliness of care. Some commenters appreciated that the measure represented a meaningful step towards streamlining data collection, improving measure efficiency, and enhancing real-time data availability to support quality improvement efforts. A commenter noted that the measure would enable healthcare organizations to optimize clinical processes, enhance patient safety, and achieve better outcomes in a timely manner.

Response: We thank commenters for their support of our proposal to adopt the Emergency Care Access & Timeliness eCQM and agree that the measure is appropriate and relevant to REHs. We agree that this measure would support healthcare organizations in achieving better outcomes.

Comment: Several commenters supported the Emergency Care Access & Timeliness eCQM as an alternative to reporting the Median Time for Discharged ED Patients measure, noting that this approach recognizes the realities of REHs, such as the technological, monetary, and staffing barriers that may present challenges to eCQM adoption and use for some REHs. Some commenters noted that this approach would enable REHs to select the option with the lower administrative burden of reporting based on their resources and clinical and administrative workflows. Some commenters requested that CMS continue to evaluate reporting for small, rural facilities, including consideration of flexible implementation strategies.

Response: We thank commenters for their support of the Emergency Care Access & Timeliness eCQM. We agree that providing REHs with the option to report either the Emergency Care Access & Timeliness eCQM or the Median Time for Discharged ED Patients measure, as discussed in section XVI.C.2.c. of this final rule with comment period, would provide greater flexibility for REHs. We are committed to ensuring flexibility that supports REHs in meeting program requirements.

Comment: Several commenters recommended publicly reporting the four individual numerator components as well as the overall measure score for the Emergency Care Access & Timeliness eCQM. Several commenters noted that data for the individual numerator components would provide more granular insights and improve hospitals' ability to target specific areas for improvement.

Response: As noted in the CY 2026 OPPS/ASC proposed rule (90 FR 33769), the Emergency Care Access & Timeliness eCQM measures four different ED numerator components in a single measure and provides REHs with separate data for each individual numerator component. We agree that such data provides meaningful and actionable information for REHs, patients, and other members of the public. While we proposed to report data for the Emergency Care Access & Timeliness eCQM as soon as feasible on a CMS website after a 30-day preview period (90 FR 33776), public reporting of these data would be contingent on the measure an REH chooses to satisfy mandatory reporting of one of the two ED-related measures in the REHQR Program measure set. Public reporting of Emergency Care Access & Timeliness eCQM data would begin once an REH has chosen to report and submitted data for the measure. This includes publicly reporting the overall score and four numerator components, in alignment with the approach taken by the Hospital OQR Program for publicly reporting a similar version of Emergency Care Access & Timeliness eCQM. We refer readers to section XV.B.1. of this final rule with comment period for more information on the Hospital OQR Program's adoption of a similar version of the Emergency Care Access & Timeliness eCQM.

Comment: Several commenters requested additional stratification factors for public reporting of the measure. Some commenters stated that they supported the measure but only with public reporting of each of the measure strata.

Response: We thank the commenters for their suggestions for additional stratifications for public reporting of the measure. The measure was evaluated by several stratification factors, and it was determined that age and mental health diagnoses were sufficient to account for differences between hospitals without further need for risk adjustment. We also note that several of the factors recommended are provider-level characteristics, and as such are not feasible to use as a patient characteristic for stratification. Additionally, we note that the Emergency Care Access & Timeliness eCQM does collect payer type, race, ethnicity, and sex as supplemental data elements; we can consider utilizing this information in support of additional future stratifications in the future. We clarify that we intend to publicly report the two mental health strata with the other two age-related strata on a CMS website.

Comment: Several commenters encouraged CMS to incorporate robust risk adjustment to account for patient case mix and volumes and the availability of post-acute care services within a hospital's service area.

Response: We thank the commenters for raising this aspect of the measure. The measure is not risk-adjusted because the numerator events are considered access failures regardless of

patient acuity or clinical comorbidity. We believe that the stratification of results by age and mental health diagnosis sufficiently accounts for differences between hospitals without risk adjustment or additional performance data detail based on analyses conducted during measure development.

Additionally, in measure testing the developer examined differences in Emergency Care Access & Timeliness score by patients' payer type composition (that is, proportion of patients with Medicaid, proportion of patients with Private/Other, and proportion of patients with Medicare) and found the strength of the relationship was weak to moderate and not statistically significant across all three of these compositional characteristics.

Comment: Some commenters requested more detailed performance metrics such as percentiles.

Response: We thank the commenters for their interest in the measure. We note that the Emergency Care Access & Timeliness eCQM is intentionally defined as a rate of access and timeliness failures. This approach focuses on a clear threshold that reflects operational and patient experience standards for accessible and timely care. Facilities may supplement this measure internally with percentile-based analyses as part of their ongoing performance improvement efforts.

Comment: Some commenters requested that CMS provide technical assistance to support REHs.

Response: Technical assistance for reporting information is available on the QualityNet website (https://qualitynet.cms.gov/reh) and questions can be submitted via the Quality Question and Answer Tool (https://cmsqualitysupport.servicenowservices.com/qnet_qa).

Comment: Several commenters did not support adoption of the Emergency Care Access & Timeliness eCQM, citing its unsuitability for REHs. These commenters noted that many rural facilities operate with limited staff, infrastructure, and technological resources, which can make implementation and reporting of complex eCQMs especially challenging. A commenter noted that most REHs operate with scaled-back electronic medical record (EMR) systems that are not designed to capture this data without costly customization and expressed concern that the reporting requirement would risk diverting scarce financial and human resources away from patient care. A few commenters expressed concern that adding a new layer of reporting would undermine the mission of the REH model, which is to preserve essential access to care in rural communities, particularly those facing severe financial distress. A commenter expressed concern that implementation of the measure beginning with the CY 2026 reporting period would be a challenge for Tribal REHs. The commenter noted that the lack of investment in Tribal REHs would hinder their ability to modernize their EHR system and urged cross-agency collaboration across HHS to modernize EHR systems for REHs. The commenter also requested that CMS make exceptions for Tribal REHs implementing new quality reporting requirements.

Response: As we noted in the CY 2026 OPPS/ASC proposed rule (90 FR 33774), while REHs may have some familiarity and experience with reporting eCQMs when formerly operating as a subsection (d) hospital or a CAH participating in the Medicare Promoting Interoperability Program, we recognize that technological, monetary, and staffing barriers may present challenges to eCQM adoption and use in some REHs. In recognition of these barriers, the anticipated implementation burden, as well as in response to public comments recommending that CMS add eCQMs as optional measures initially (88 FR 82070), we proposed that the Emergency Care Access & Timeliness eCQM would not be a required measure under the REHQR Program, and that REHs could thus elect to report either the Emergency Care Access & Timeliness eCQM or the Median Time for Discharged ED Patient measure for a given reporting period/ program determination (90 FR 33771 and 33772). Given this flexibility, we believe that this approach, which we are finalizing, is compatible with the intent of the REH model and will provide REHs, including Tribal REHs, with more flexibility to implement the measure in a way that meets individual REH's needs. We also note that we proposed for this measure to begin with the CY 2027 reporting period, not the CY 2026 reporting period as the commenter noted.

Comment: Some commenters expressed concern that factors outside of an REH's control (such as weather or transportation barriers) may impact measure performance.

Response: Although we acknowledge that measure performance could be affected by multiple factors both inside and outside the control of REHs, measurement is essential for tracking and addressing these complex systemic issues and their downstream effects. By measuring the variation in access to and timeliness of care nationally, the measure builds an evidence base to determine which REHs are meeting benchmarks for emergency care, and which REHs could see improvement. Many REHs face similar challenges with factors such as weather or transportation barriers; however, the information collected through the Emergency Care Access & Timeliness eCQM can help patients and their caregivers compare REH performance and inform REH quality improvement efforts. We also note that we examined Median Time from Arrival to Departure metrics in the CY 2024 OPPS/ASC rulemaking and found that smaller, rural hospitals did not have lower performance than larger, urban hospitals.

Comment: A commenter recommended evaluating receiving facilities instead of REHs for numerator component (3) which evaluates the time from Decision to Transfer (order) to the ED departure.

Response: We thank the commenter for underscoring the importance of the time from Decision to Transfer (order) to the ED departure, one of the numerator components for the measure. We note that REHs are statutorily required to have in effect a transfer agreement with a level I or level II trauma center, such that patients that present at an REH with needs for longer-term inpatient care may receive that care. REHs must, therefore, address issues related to the coordination of care for transferred patients. We note that we intend to publicly report all strata of the measure so that this information is available for evaluation purposes.

Comment: Another commenter noted that CMS should focus instead on measures that rely on data sources already collected and available, such as claims data, cost reports, or Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys.

Response: We note that three out of the four measures in the REHQR Program measure set are claims-based. As REHs are statutorily required to provide ED services, we believe it is important that the REHQR Program include one or more measures related to these services. We have provided flexibility to REHs regarding which ED services measure to report, the Emergency Care Access & Timeliness eCQM or the Median Time for Discharged Patients measure. Regarding the commenter's suggestion to use HCAHPS survey data, we note that the HCAHPS survey is designed for the

inpatient setting,\386\ and would thus not be suitable for the REH setting.

\386\ Centers for Medicare & Medicaid Services. (December 2024). HCAHPS Fact Sheet. Available at https://hcahpsonline.org/globalassets/hcahps/facts/hcahps_fact_sheet_december_2024.pdf.

Comment: A commenter did not support the Emergency Care Access & Timeliness eCQM because it was developed and tested for use in the hospital outpatient setting. The commenter stated that all measures must be tested at the REH level and demonstrate a high level of reliability, feasibility, and validity.

Response: We recognize the value of measures undergoing testing and evaluation of reliability, feasibility, and validity in the setting for which they are being adopted. As part of the PRMR process, the Emergency Care Access & Timeliness eCQM underwent an assessment of the measure's testing data and appropriateness for the REH setting, including a review of the measure's scientific acceptability, feasibility, and usability. As explained in the CY 2026 OPPS/ASC proposed rule (90 FR 33770), although data element feasibility testing was performed at only one REH, the measure was also tested at some rural hospital EDs with similar characteristics of pre-conversion REHs.\387\ Based on this, we believe these measure testing results are applicable to REHs. We refer readers to the CY 2026 OPPS/ASC proposed rule (80 FR 33770 through 33771) for further discussion of the measure's review and evaluation.

\387\ Partnership for Quality Measurement. Section 7.1 Supplemental Attachment. Available at https://p4qm.org/sites/default/files/2024-10/4625e-section-7.1-supplemental-attachment.pdf.

Comment: A commenter noted that the low volumes treated by these facilities likely would be incompatible with the Emergency Care Access & Timeliness eCQM's calculation methodology.

Response: Regarding the commenter's concern about low case volumes, we refer readers to the CY 2026 OPPS/ASC proposed rule (90 FR 33771) for discussion of our consideration of low case volumes prior to proposing this measure for adoption in the REH setting. Given the denominator includes all ED visits over a 1-year measurement period, we anticipate that there would not be any issues with low case volumes that could undermine the reliability of this measure for REHs.

After consideration of the public comments we received, we are finalizing our proposal to adopt the Emergency Care Access & Timeliness eCQM into the REHQR Program, beginning with the CY 2027 reporting period/CY 2029 program determination as proposed. We also refer readers to section XVI.C.2.c. of this final rule with comment period where we finalize the data submission and reporting requirements for the Emergency Care Access & Timeliness eCQM as proposed, such that the Emergency Care Access & Timeliness eCQM would not be required to be reported by REHs under the REHQR Program, but REHs must nonetheless report either the Emergency Care Access & Timeliness eCQM or the Median Time for Discharged ED Patients measure to meet program requirements, beginning with the CY 2027 reporting period/CY 2029 program determination. 2. Summary of Previously Finalized and Newly Finalized REHQR Program Measure Set for CY 2026 to CY 2031 Program Determinations

Table 139 summarizes the previously finalized and newly finalized REHQR Program measure set for the CY 2026 to CY 2031 program determinations, which removes the Hospital Commitment to Health Equity (HCHE), Screening for SDOH, and Screen Positive Rate for SDOH measures as discussed in section XIV.C. of this final rule with comment period and adds the Emergency Care Access & Timeliness eCQM as discussed in section XVI.B.1. of this final rule with comment period. BILLING CODE 4120-01-P

[GRAPHIC] [TIFF OMITTED] TR25NO25.225

BILLING CODE 4120-01-C

We refer readers to the QualityNet website at https://qualitynet.cms.gov/reh/rehqr for additional information on the reporting periods and submission deadlines for each measure finalized and proposed in the REHQR Program. 3. REHQR Program Measures and Topics for Future Consideration

We refer readers to section XIV.B. of this final rule with comment period for our cross-program Request for Information on measure concepts regarding well-being and nutrition for consideration in the REHQR Program.

In the CY 2026 OPPS/ASC proposed rule (90 FR 33774 through 33776), we proposed to update program policies for introducing eCQMs into the REHQR Program by establishing eCQM data submission and reporting requirements which apply to the proposed Emergency Care Access & Timeliness eCQM. 1. Maintenance of Technical Specifications for Quality Measures

CMS maintains technical specifications for adopted REHQR Program measures. The manuals containing the specifications for adopted measures are on the QualityNet website at https://qualitynet.cms.gov/reh/specifications-manuals. We refer readers to the CY 2024 OPPS/ASC final

rule with comment period (88 FR 82054) for additional information regarding these specification manuals.

In the CY 2026 OPPS/ASC proposed rule (90 FR 33774), in alignment with the Hospital OQR Program, we proposed that the technical specifications for eCQMs for the REHQR Program would be contained in the CMS Annual Update for the Hospital Quality Reporting Programs (Annual Update). The Annual Update and implementation guidance documents are available on the eCQI Resource Center website at https://ecqi.healthit.gov/. For eCQMs, we would generally update the measure specifications on an annual basis through the Annual Update which includes code updates, logic corrections, alignment with current clinical guidelines, and additional guidance for REHs and EHR vendors to collect and submit data on eCQMs from EHRs.

We invited public comments on this proposal.

We did not receive public comments on this proposal, and therefore, we are finalizing the policy for maintaining technical specifications for eCQMs as proposed. 2. Data Submission and Reporting Requirements for eCQMs for the REHQR Program Beginning With the CY 2027 Reporting Period/CY 2029 Program Determination a. Background

Collection and reporting of data through health information technology greatly simplifies and streamlines quality reporting, and automated electronic extraction and reporting of clinical quality data would significantly reduce the administrative burden on REHs for the REHQR Program. Certified EHR technology (CEHRT) could effectively assist REHs in a variety of ways, such as by improving coordination of care with receiving hospitals during transfers, facilitating the types of staffing and personnel models required for REHs, and using eCQMs to improve quality and safety. In response to our request for comments in the CY 2024 OPPS/ASC proposed rule (88 FR 49840 through 49841) on eCQM reporting for the REHQR Program, some commenters recommended that CMS should consider adding eCQMs as optional measures initially (88 FR 82070). REHs have some familiarity and experience with reporting eCQMs when formerly operating as a subsection (d) hospital or CAH participating in the Medicare Promoting Interoperability Program, although we acknowledge that technological, monetary, and staffing barriers may present challenges to eCQM adoption and use in some REHs.

We refer readers to section XVI.B.1. of this final rule with comment period, where we finalize adoption of the Emergency Care Access & Timeliness eCQM into the REHQR Program measure set as an optional measure, beginning with the CY 2027 reporting period/CY 2029 program determination. The Emergency Care Access & Timeliness eCQM is the first eCQM in the REHQR Program measure set. Introducing eCQM reporting to the REHQR Program involves establishing related policies and requirements, such as eCQM certification requirements, data standards and formats, submission methods, and other program-specific requirements. In the following sections, to reduce reporting burden for REHs, we proposed eCQM reporting and submission policies and requirements for the REHQR Program, including reporting of the Emergency Care Access & Timeliness eCQM, that align with those of the Hospital OQR Program, Hospital Inpatient Quality Reporting Program, and Medicare Promoting Interoperability Program. b. General Data Submission Requirements and Reporting Requirements (1) eCQM Certification Requirements for eCQM Reporting

In the CY 2025 OPPS/ASC final rule with comment period (89 FR 94418 through 94420), the Hospital OQR Program finalized and codified three requirements relating to eCQM certification for the submission of eCQM data, beginning with the CY 2025 reporting period/CY 2027 payment determination. In the CY 2026 OPPS/ASC proposed rule, we proposed adopting the same eCQM certification requirements in the REHQR Program, beginning with the CY 2027 reporting period/CY 2029 program determination, and to likewise codify them by adding new paragraph (h) “Requirements for submission of electronic clinical quality measures (eCQMs) under the REHQR Program” to Sec. 419.95 (90 FR 33774 through 33775). As discussed in section XVI.C.2.c. of this final rule with comment period, REHs would be required to meet these eCQM requirements beginning with the CY 2027 reporting period/CY 2029 program determination if the REH chooses to submit the Emergency Care Access & Timeliness eCQM rather than the Median Time for Discharged ED Patients measure.

Under this approach, we proposed to codify at Sec. 419.95(h)(1) the requirement for REHs to utilize technology certified to Office of the National Coordinator for Health Information Technology's (ONC's) health information technology (IT) certification criteria, as adopted and updated in 45 CFR 170.315, for reporting eCQMs under the REHQR Program. Using the most recent certified health IT, which includes updated standards and criteria, is important as it allows the collection of relevant, accurate, and structured electronic data for electronic clinical quality measurement.

We also proposed to codify at 42 CFR 419.95(h)(2) the requirement that the health IT used for eCQM reporting by REHs must be certified to all eCQMs (that is, tested and validated on each individual eCQM) available to report under the REHQR Program. Additionally, we proposed to codify at Sec. 419.95(h)(3) the requirement that REHs use the most recent version of the eCQM electronic measure specifications for the applicable reporting period available on the Electronic Clinical Quality Improvement (eCQI) Resource Center website at https://ecqi.healthit.gov/ or another website as designated by CMS. We also proposed that certified EHR technology would not need to be recertified each time the eCQMs specifications are updated to a more recent version.

Requiring EHRs to be certified to all available eCQMs under the REHQR Program would produce greater certainty for REHs that their EHR systems are capable of accurately calculating the eCQMs under the REHQR Program because the EHR technology would be up to date and tested on each eCQM. We believe this would reduce burden on REHs by minimizing the need to consult with their EHR and other health information technology vendors each time they report on a new or different eCQM.

Finally, we also proposed to codify at Sec. 419.95(h)(4) that the requirements set forth in paragraphs (h)(1) through (3) apply only where an REH opts to report an eCQM.

We invited public comments on these proposals.

We did not receive public comments on these proposals, and therefore, we are finalizing the eCQM certification requirements for eCQM reporting as proposed and to codify these requirements by adding new paragraph (h) “Requirements for submission of electronic clinical quality measures (eCQMs) under the REHQR Program” to Sec. 419.95.

(2) File Format for EHR Data, Zero Denominator Declarations, and Case Threshold Exemptions (a) File Format for EHR Data

Data can be collected in EHRs and health information technology systems using standardized formats to promote consistent representation, interpretation, and allowance for systems to compute data without needing human interpretation. As described in the FY 2016 IPPS/LTCH PPS final rule (80 FR 49701), these standards are referred to as content exchange standards because the standard details how data should be represented and the relationships between data elements. This allows the data to be exchanged across EHRs and health IT systems while retaining their meaning. Commonly used content exchange standards include the Quality Reporting Document Architecture (QRDA). The QRDA standard provides a document format and standard structure to electronically report quality measure data. We believe electronically reporting data elements formatted according to the QRDA standard can promote consistent representation and more efficient calculation of eCQM measure results.

To utilize the same file format requirements currently applied in the Hospital IQR, OQR, and Medicare Promoting Interoperability Programs (85 FR 58940, 86 FR 42262, and 80 FR 49706, respectively), in the CY 2026 OPPS/ASC proposed rule (90 FR 33775), we proposed the file format requirements for the REHQR Program beginning with the CY 2027 reporting period/CY 2029 program determination. Specifically, we proposed that REHs: (1) must submit eCQM data via the QRDA Category I (QRDA I) file format; \388\[thinsp](2) may use third parties to submit QRDA I files on their behalf; and (3) may either use abstraction or pull the data from non-certified sources in order to then input these data into CEHRT for capture and reporting QRDA I. REHs could meet the reporting requirements by submitting data via QRDA I files, zero denominator declaration, or case threshold exemptions. We discuss the zero denominator declaration and case threshold exemptions in the subsequent sections. We also refer readers to section XVI.C.1. of this final rule with comment period where we outline the maintenance of technical specifications including those for eCQMs.

\388\ QRDA I is an individual patient-level quality report that contains quality data for one patient for one or more eCQMs. QRDA creates a standard method to report quality measure results in a structured, consistent format and can be used to exchange eCQM data between systems. For further detail on QRDA I, the most recently available QRDA I specifications and Implementation Guides (IGs) can be found at https://ecqi.healthit.gov/qrda/versions.

Under this proposal, we expect QRDA I files to reflect data for one patient per file per quarter with five key elements necessary to identify the file: (1) CCN; (2) CMS Program Name; (3) EHR Patient ID; (4) Reporting period specified in the Reporting Parameters Section; and (5) EHR Submitter ID. (b) Zero Denominator Declarations

We understand there may be situations in which an REH does not have data to report on a particular eCQM. Therefore, we proposed if the REH's EHR is certified to an eCQM, but the REH does not have patients that meet the denominator criteria of that eCQM, the REH could submit a zero in the denominator for that eCQM; submission of a zero in the denominator for an eCQM would qualify as a successful submission for that eCQM (90 FR 33775). (c) Case Threshold Exemptions

As a general matter, we understand that in some cases, particularly for REHs, an REH may not meet the applicable case threshold of encounters or discharges for a particular eCQM to reliably calculate performance on the measure. In the CY 2026 OPPS/ASC proposed rule (90 FR 33775), we proposed to align with the case threshold exemption from the Medicare Promoting Interoperability Program (77 FR 54080), the Hospital IQR Program (79 FR 50324), and the Hospital OQR Program (86 FR 63869). As stated for the Hospital IQR Program, the case threshold exemption means that for each quality measure where the minimum number of patients that meet the patient population denominator criteria for the relevant reporting period is not met, REHs could declare a “case threshold exemption.” Specifically, for the REHQR Program, we proposed that beginning with the CY 2027 reporting period/CY 2029 program determination, if an REH's EHR system is certified to report an eCQM and the REH has 5 or fewer outpatient encounters or discharges per quarter or 20 or fewer outpatient encounters or discharges per year (Medicare and non-Medicare combined), as defined by an eCQM's denominator population, that REH would be exempt from reporting on that eCQM. Case threshold exemptions would be able to be entered on the Denominator Declaration screen within the Hospital Quality Reporting (HQR) System (formerly referred to as the QualityNet Secure Portal) available during the submission period.\389\ The exemption would not have to be used; REHs could report those individual cases if they would like to.

\389\ The Hospital Quality Reporting (HQR) System (formerly referred to as the QualityNet Secure Portal) is the only CMS- approved website for secure communications and healthcare quality data exchange to and within various CMS quality reporting programs. For more information regarding the HQR System, we refer readers to the CMS eCQI Resource Center available at https://ecqi.healthit.gov/tool/hospital-quality-reporting-hqr-system.

We invited public comments on these proposals.

Comment: A commenter supported our proposals related to zero denominator declarations and case threshold exemptions. The commenter particularly appreciated that the proposed case threshold exemption policy aligns with the Medicare Promoting Interoperability Program, the Hospital IQR Program, and the Hospital OQR Program.

Response: We thank the commenter for their support for our proposals related to zero denominator declarations and case threshold exemptions.

Comment: A commenter requested that CMS align eCQM submission formats across quality reporting programs.

Response: We note that in the CY 2026 OPPS/ASC proposed rule (90 FR 33775), we proposed to utilize the same file format requirements--the QRDA standard--applied in the Hospital IQR, OQR, and Medicare Promoting Interoperability Programs (85 FR 58940, 86 FR 42262, and 80 FR 49706, respectively).

After consideration of the public comments we received, we are finalizing the proposals related to the file format for EHR data, zero denominator declarations, and case threshold exemptions as proposed. (3) Submission Deadlines for eCQM Data

To align with the Hospital OQR Program, in the CY 2026 OPPS/ASC proposed rule (90 FR 33775), we proposed to adopt a policy to require eCQM data submission by May 15 of the following year for the applicable CY reporting period, beginning with the CY 2027 reporting period/CY 2029 program determination. For example, if an REH elects to report the Emergency Care Access & Timeliness eCQM, the first proposed reporting period would run from January 1, 2027, through December 31, 2027, with a submission deadline of May 15, 2028. We note that the submission deadline may be moved to a subsequent day if it falls on a non-working day for Federal employees such as weekends or Federal holidays.

We invited public comments on this proposal.

We did not receive public comments on this proposal, and therefore, we are finalizing the submission deadlines for eCQM data as proposed. c. Data Submission and Reporting Requirements for the Emergency Care Access & Timeliness eCQM Beginning With the CY 2027 Reporting Period/CY 2029 Program Determination

In section XVI.B.1. of this final rule with comment period, we finalize the adoption of the Emergency Care Access & Timeliness eCQM into the REHQR Program beginning with the CY 2027 reporting period/CY 2029 program determination as an option for REHs to report instead of the Median Time for Discharged ED Patients measure. In addition to the general data submission and reporting requirements finalized for eCQMs in section XVI.C.2. of this final rule with comment period, in the CY 2026 OPPS/ASC proposed rule (90 FR 33775 through 33776), we also proposed requirements for reporting the Emergency Care Access & Timeliness eCQM under the REHQR Program. Specifically, we proposed that the Emergency Care Access & Timeliness eCQM would not be required to be reported by REHs under the REHQR Program, but that REHs must elect to report either the Emergency Care Access & Timeliness eCQM or the Median Time for Discharged ED Patients measure to meet program requirements, beginning with the CY 2027 reporting period/CY 2029 program determination. We stated that we believe our approach would provide REHs with more flexibility, including the time to plan and budget for the type of EHR infrastructure that meets their needs. Additionally, we noted this approach could contribute to successful participation in the REHQR Program, while still requiring REHs to report timeliness of ED care metrics. We also noted that the Median Time for Discharged ED Patients measure is reported quarterly through the HQR system, compared to the Emergency Care Access & Timeliness eCQM, which is reported annually. Sources of the relevant data for the Median Time for Discharged ED Patients measure may include claims forms, electronic health care data, EHRs, or paper records. We refer readers to the CY 2024 OPPS/ASC final rule with comment period (88 FR 82059 through 82062; 88 FR 82074 through 82075) for additional information on reporting the chart-abstracted Median Time for Discharged ED Patients measure.\390\

\390\ For additional information on the Median Time for Discharged ED Patients measure, we refer readers to the specifications manuals for the REHQR Program, available at https://qualitynet.cms.gov/reh/specifications-manuals.

In the CY 2026 OPPS/ASC proposed rule (90 FR 33776), we proposed to report data from the REHQR Program as soon as it is feasible on a CMS website after a 30-day preview period.

We invited public comments on these proposals.

Comment: A few commenters recommended that CMS extend voluntary reporting of the Emergency Care Access & Timeliness eCQM in the REHQR Program to support a smoother transition to eCQM reporting and provide REHs with time needed to build capacity, train staff, and prepare systems, without compromising care or financial stability. Another commenter recommended mandatory reporting and retiring the Median Time for Discharged ED Patients, for measure alignment purposes.

Response: In the CY 2026 OPPS/ASC proposed rule (90 FR 33775 through 33776), we proposed that the Emergency Care Access & Timeliness eCQM would not be required to be reported by REHs under the REHQR Program, but that REHs report either the Emergency Care Access & Timeliness eCQM or the Median Time for Discharged ED Patients measure to meet program requirements, beginning with the CY 2027 reporting period/CY 2029 program determination. As discussed in greater depth in section XVI.B.1 of this final rule with comment period, CMS is finalizing its proposal to adopt the Emergency Care Access & Timeliness eCQM as an optional measure that REHs may choose to report instead of the existing Median Time for Discharged ED Patients measure. This approach is intended to ensure flexibility for REHs which may face barriers to implementing eCQMs.

After consideration of the public comments we received, we are finalizing the data submission and reporting requirements for the Emergency Care Access & Timeliness eCQM as proposed, such that the Emergency Care Access & Timeliness eCQM would not be required to be reported by REHs under the REHQR Program, but REHs report either the Emergency Care Access & Timeliness eCQM or the Median Time for Discharged ED Patients measure to meet program requirements, beginning with the CY 2027 reporting period/CY 2029 program determination. 3. Review and Corrections Period for Measure Data Submitted to the REHQR Program

In the CY 2024 OPPS/ASC final rule with comment period (88 FR 82075 through 82076), we finalized and codified at Sec. 419.95(c)(3) a review and corrections period for all measure data submitted to the REHQR Program, which runs concurrently with the data submission period. During the review and corrections period, REHs can review, correct, and change these data up until the close of each submission deadline. However, after the submission deadline, REHs are not allowed to change these data. This policy applies to all measure data submitted to the REHQR Program, so this would include eCQM data.

The review and corrections period is from the time the submission period opens to the submission deadline. In the HQR System, REHs can submit QRDA Category I test and production data files and can correct QRDA Category I test and production data files before production data is submitted for final reporting. We encourage early testing and the use of pre-submission testing tools to reduce errors and inaccurate data submissions in eCQM reporting. We refer readers to the HQR System website (available at https://hqr.cms.gov/hqrng/login) and the CMS eCQI Resource Center (available at https://ecqi.healthit.gov/tool/hospital-quality-reporting-hqr-system) for more resources on eCQM reporting.

We invited public comments on this proposal.

Comment: A commenter supported our proposal to apply the review and corrections period for eCQM data submitted for the REHQR Program. The commenter noted that this policy reflects the workflow of many practices to periodically review progress, adjust their behaviors as necessary, and appreciated the opportunity to review and correct measure during the submission period.

Response: We thank the commenter for their support.

After consideration of the public comments we received, we are finalizing the review and corrections period for eCQM data as proposed. 4. REHQR Program Extraordinary Circumstances Exceptions (ECE) Policy

We refer readers to section XIV.D. of this final rule with comment period where we finalize with modification our cross-program proposal to codify updates to the Extraordinary Circumstances Exceptions (ECE) policy for the REHQR Program.

In the CY 2026 OPPS/ASC proposed rule, we proposed to adopt the Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure (Information Transfer PRO-PM) beginning with voluntary reporting for the CY 2027 and CY 2028 reporting periods followed by mandatory reporting beginning with the CY 2029 reporting period/CY 2031 payment determination (90 FR 33777 through 33779).

We refer readers to section XIV.C. of this final rule with comment period for a discussion of the following measure removals: (1) the COVID-19 Vaccination Coverage Among Healthcare Personnel (HCP) measure, beginning with the CY 2024 reporting period/CY 2026 payment determination; (2) the Facility Commitment to Health Equity (FCHE) measure, beginning with the CY 2025 reporting period/CY 2027 payment determination; (3) the Screening for Social Drivers of Health (SDOH) measure, beginning with the CY 2025 reporting period; and (4) the Screen Positive Rate for SDOH measure, beginning with the CY 2025 reporting period. 1. Proposed Adoption of the Information Transfer PRO-PM Beginning With Voluntary Reporting for the CY 2027 and CY 2028 Reporting Periods Followed by Mandatory Reporting Beginning With the CY 2029 Reporting Period/CY 2031 Payment Determination a. Background

The volume and complexity of surgical procedures performed in outpatient settings, including ASCs, have steadily increased for over a decade.391 392 393 As patients can benefit from having a clear understanding of their discharge information to support recovery from such procedures, the communication of discharge information is an important quality of care area for assessing facilities, and this information should be publicly available. A patient's lack of understanding of clinical care instructions provided after a procedure and other aspects of health literacy have been linked to poor adherence to treatment, decreased patient safety, increased return to the emergency department, and lower levels of patient satisfaction; disproportionately increased rates of such adverse effects occur to patients with limited English proficiency and patients over age 65.394 395 Research in the hospital setting indicates that information provided to patients that is simpler and more complete is associated with fewer follow-up calls to an associated trauma center and less frequent hospital readmissions.396 397 A study comparing discharge instructions provided to patients who had procedures performed in inpatient and ambulatory settings found that discharge instructions from the inpatient setting contained more complete medication lists and pending diagnostic result elements compared to discharge instructions provided by the hospital ambulatory setting.\398\

\391\ DelSole, E.M., Makanji, H.S., & Kurd, M.F. (2019). Current trends in ambulatory spine surgery: a systematic review. J Spine Surg. 5(Suppl 2):S124-S132. Available at https://doi.org/10.21037/jss.2019.04.12. Accessed: April 29, 2025.

\392\ Kondamuri, N.S., Miller, A.L., Rathi, V.K., et al. (2020). Trends in Ambulatory Surgery Center Utilization for Otolaryngologic Procedures among Medicare Beneficiaries, 2010-2017. Otolaryngol Head Neck Surg. 162(6):873-880. Available at https://doi.org/10.1177/0194599820914298. Accessed: April 29, 2025.

\393\ Shariq, O.A., Bews, K.A., Etzioni, D.A., et al. (2023). Performance of General Surgical Procedures in Outpatient Settings Before and After Onset of the COVID-19 Pandemic. JAMA Netw Open.; 6(3):e231198. Available at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2801919. Accessed: April 29, 2025.

\394\ DeSai, C., Janowiak, K., Secheli, B., et al. (2021). Empowering patients: simplifying discharge instructions. BMJ Open Quality; 10(3)001419. Available at http://doi.org/10.1136/bmjoq-2021-001419. Accessed: April 8, 2025.

\395\ Malevanchik, L., Wheeler, M., Gagliardi, K., Karliner L., & Shah, S.J. (2021). Disparities After Discharge: The Association of Limited English Proficiency and Postdischarge Patient-Reported Issues. Available at The Joint Commission Journal on Quality and Patient Safety, 47(12):775-782. https://doi.org/10.1016/j.jcjq.2021.08.013. Accessed: April 8, 2025.

\396\ Choudhry, A.J., Younis, M., Ray-Zack, M.D., et al. (2019). Enhanced readability of discharge summaries decreases provider telephone calls and patient readmissions in the posthospital setting. Surgery. 165(4):789-794. Available at https://doi.org/10.1016/j.surg.2018.10.014. Accessed: April 8, 2025.

\397\ Becker, C., Zumbrunn, S., Beck, K., et al. (2021). Interventions to Improve Communication at Hospital Discharge and Rates of Readmission: A Systematic Review and Meta-analysis. JAMA Netw Open. 4(8):e2119346. Available at https://doi.org/10.1001/jamanetworkopen.2021.19346. Accessed: April 8, 2025.

\398\ Downey, E., & Olds, D.M. (2021). Comparison of Documentation on Inpatient Discharge and Ambulatory End-of-Visit Summaries. Journal of Healthcare Quality. 43(3):e43-e52. Available at https://doi.org/10.1097/JHQ.0000000000000269. Accessed: April 8, 2025.

The Information Transfer PRO-PM assesses patient understanding of provided discharge information for patients aged 18 years or older who had a procedure (surgical or non-surgical) at an ASC via a 9-item survey.\399\ The survey evaluates patient reported understanding of information received across three domains: applicability to patient needs, medication, and daily activities. Survey results provide patient reported outcome (PRO) data measuring ASCs' communication efforts regarding discharge instructions and enable ASCs to reduce future risk of patient harm related to patients not fully understanding their recovery information. The survey was tested and deemed reliable in both English and Spanish versions; for ease of administration, the survey can be completed using a translator, proxy, or caregiver. The measure's testing results

are based on data from the hospital outpatient department (HOPD) setting; however, it is reasonably expected that the instrument and methodology apply to the ASC setting regarding patients receiving surgical procedures as both are outpatient surgical settings providing similar services with the supply of discharge instructions. We note that the measure specifications for the Information Transfer PRO-PM require that the survey be administered anonymously to patients and that the survey instrument does not collect any identifiable patient information.

\399\ A copy of the survey instrument is available at https://www.cms.gov/files/document/patient-understanding-key-information-related-recovery-after-facility-based-outpatient-procedure-or.pdf.

In monitoring implementation of this measure for the Hospital OQR Program, we discovered that the anonymous administration requirement could potentially limit the hospitals' ability to collect data for their patients without working with a third-party vendor. If the survey is required to be fully anonymous, hospitals fielding the survey themselves would not be able to conduct any targeted follow-up with patients during the 65-day response window or use the information provided to develop more targeted quality improvement efforts.

While anonymous surveys can be valuable for gathering candid feedback, these issues of preventing follow-up, targeted action plans, and deeper investigation of specific issues, as well as leading to less serious or misleading responses have been documented.\400\

\400\ Murdoch, M., et al. (2014). Impact of different privacy conditions and incentives on survey response rate, participant representativeness, and disclosure of sensitive information: a randomized controlled trial. BMC Medical Research Methodology. July 16:14-90. Available at https://bmcmedresmethodol.biomedcentral.com/articles/10.1186/1471-2288-14-90. Accessed: October 29, 2025.

In the CY 2026 OPPS/ASC proposed rule, we invited public comment on the proposal to utilize this measure as specified with anonymous administration as well as potential data collection options to address the anonymity requirement in both the Hospital OQR Program, where the measure has already been adopted, and the ASCQR Program, where this measure was proposed for adoption (90 FR 33777).

The measure developer conducted pilot testing for this measure in 26 HOPDs in five states and demonstrated that the measure is reliable and meaningful.\401\ Reliability of the measure was assessed with the Cronbach alpha score \402\ to determine whether the nine survey questions reliably measured the same underlying characteristic; that is, patient's assessment of the clarity and applicability of recovery instructions. The Cronbach alpha score indicated that the survey items are reliable.\403\ The measure developer also found the performance scores among facilities in the pilot study to be moderately reliable using a signal-to-noise ratio, which estimated variance among facilities and measured facility-specific standard errors to determine the extent to which variance in facility scores can be attributed to variance in actual performance.\404\ More information about the testing, feasibility, scientific acceptability, meaningfulness, and validity of the Information Transfer PRO-PM for the HOPD setting is available at https://p4qm.org/measures/4210.

\401\ Centers for Medicare & Medicaid Services. (April 2024). Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure. Available at https://www.cms.gov/files/document/patient-understanding-key-information-related-recovery-after-facility-based-outpatient-procedure-or.pdf. Accessed: April 29, 2025.

\402\ For more information on what the Cronbach alpha score determines and how it is used, we refer readers to: Tavakol, M., & Dennick, R. (2011). Making sense of Cronbach's alpha. Int J Med Educ. 27;2: 53- 55. https://www.ijme.net/archive/2/cronbachs-alpha.pdf. Accessed: April 30, 2025.

\403\ Centers for Medicare & Medicaid Services. (April 2024). Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure. Available at https://www.cms.gov/files/document/patient-understanding-key-information-related-recovery-after-facility-based-outpatient-procedure-or.pdf. Accessed: April 29, 2025.

\404\ Centers for Medicare & Medicaid Services. (April 2024). Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure. Available at https://www.cms.gov/files/document/patient-understanding-key-information-related-recovery-after-facility-based-outpatient-procedure-or.pdf. Accessed: April 29, 2025.

As required under section 1890A of the Act, the Secretary must establish and follow a pre-rulemaking process for the selection of quality and efficiency measures, including for the ASCQR Program. The pre-rulemaking process, which we refer to as the Pre-Rulemaking Measure Review (PRMR), includes a review of measures published on the publicly available list of Measures Under Consideration (MUC List) by one of several committees convened by the consensus-based entity (CBE), with which we contract in accordance with section 1890 of the Act, for the purpose of providing interested parties' input to the Secretary on the selection of quality and efficiency measures under consideration for use in certain Medicare quality programs, including the ASCQR Program. We refer readers to the CY 2025 OPPS/ASC final rule with comment period (89 FR 94372) for details on the PRMR process, including the voting procedures used to reach consensus on measure recommendations.

The PRMR Hospital Recommendation Group met on January 15 and 16, 2025 to review measures included by the Secretary on the publicly available “2024 Measures Under Consideration List” (MUC List), including the Information Transfer PRO-PM, for potential use.407 408 The voting results of the PRMR Hospital Recommendation Group for the proposed Information Transfer PRO-PM for the ASCQR Program were: 5 members recommended adopting the measure; 14

members recommended adoption with conditions; and 8 members voted not to recommend the measure for adoption. No voting category reached 75 percent or greater, including the combination of the recommend and the recommend with conditions categories. Thus, the PRMR Hospital Recommendation Group did not reach consensus and did not recommend including this measure in the ASCQR Program either with or without conditions.

\407\ The Information Transfer PRO-PM is identified on the MUC List as MUC2024-073.

\408\ Partnership for Quality Measurement. (2025). 2024-2025 Pre-Rulemaking Measure Review (PRMR) Recommendation Group Final Meeting Summary: Hospital Committee. Available at https://p4qm.org/sites/default/files/2025-02/PRMR-Hospital-Recommendation-Group-Meeting-Summary.pdf. Accessed: April 29, 2025.

The PRMR Hospital Recommendation Group noted in their deliberations the importance of measuring patient experience and delivering personalized and clear discharge instructions to prevent unnecessary hospital readmissions. However, the PRMR Hospital Recommendation Group members expressed concerns about lack of testing in the ASC setting given differences between HOPDs as a hospital setting (where testing of the Information Transfer PRO-PM was conducted) and ASCs. This group also highlighted concerns related to patient survey fatigue; potential overlap with the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey sample population and content; and the risk of low response rates-- particularly in small or rural facilities, which could impact scoring.

Although the measure was not pilot tested in the ASC setting with facilities citing resource constraints, we believe that the instrument and methodology reasonably apply to the ASC setting as the measure concept was designed for use in both HOPDs and ASCs and many of the same surgical procedures are performed in both settings.\409\ Measure harmonization across the Hospital OQR and ASCQR Programs enables meaningful comparisons of care for patients to assess quality between settings that offer similar services.

\409\ Centers for Medicare & Medicaid Services. (April 2024). Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure. Available at https://www.cms.gov/files/document/patient-understanding-key-information-related-recovery-after-facility-based-outpatient-procedure-or.pdf. Accessed: April 29, 2025.

Regarding the PRMR Hospital Recommendation Group's concern about potential overlap between the Information Transfer PRO-PM and OAS CAHPS content and target population, the OAS CAHPS survey addresses overall quality of healthcare facility communication but does not assess patient understanding of discharge information related to medication, activity, and applicability/personalization. We believe that both surveys provide valuable insights into different aspects of a patient's experience related to discharge instructions. Additionally, to minimize duplication of patient sampling, resources are available to help facilities align administration of OAS CAHPS with other surveys.\410\ In consideration of potential population overlap, we selected a timeframe of 2 to 7 days post-procedure for administration of the Information Transfer PRO-PM's survey to strike a balance between patient recovery and mitigate overlap with the initial administration of OAS CAHPS.

\410\ OAS CAHPS. (2024). 2024 Introduction to the OAS CAHPS Survey, Self-Paced Training. Available at https://oascahps.org/Training/Training-Materials. Accessed: April 29, 2025.

Regarding concerns about patient survey fatigue and risk of low response rates, the 9-item survey is concise, presenting a low burden for completion. Further, ASCs would not be penalized for patients' decisions to not complete the survey. Payment implications under the ASCQR Program are tied to the successful and timely reporting of required quality measure data, and an ASC that submits data to CMS in the form, manner, and timing specified, regardless of the number of surveys completed by the ASC's patient population, would be considered compliant with the measure requirements.

To review the Hospital Recommendation Group's voting summary, recommendations, and conditions for the Information Transfer PRO-PM please visit https://p4qm.org/PRMR/Resources. e. Measure Endorsement

Under section 1833(i)(7)(B) of the Act, requirements for the development of outpatient measures for the Hospital OQR Program at section 1833(t)(17)(C) of the Act apply to the ASCQR Program, except as the Secretary may otherwise provide. Section 1833(t)(17)(C)(i) of the Act requires measures developed to reflect consensus among affected parties and, to the extent feasible and practicable, shall include measures set forth by one or more national consensus-based entities (not necessarily the contracted CBE). As we have noted in previous rulemaking, consensus among affected parties can be reflected in ways other than CBE endorsement, including through the measure development process, through broad acceptance and use of the measure(s), and through public comment (76 FR 74494). We have also noted that section 1833(t)(17) of the Act does not require that each measure we adopt for the ASCQR Program be CBE-endorsed (76 FR 74494).

A Technical Expert Panel consisting of interested parties, experts, and consumer advocates contributed to the development of the Information Transfer PRO-PM measure's survey design, measure cohort, and survey implementation, demonstrating a consensus-based approach to the measure's development.\411\

\411\ Centers for Medicare & Medicaid Services. (March 22). Methodology Report For Public Comment: Patient Understanding of Key Information Related to Recovery From an Outpatient Surgery or Procedure. Available at https://www.cms.gov/files/document/methodology-report-public-comment.pdf. Accessed: April 29, 2025.

In the CY 2026 OPPS/ASC proposed rule, we explained that while we recognize the value of measures undergoing CBE endorsement review and prefer to use endorsed measures, at that time, we found no other CBE- endorsed measures for the ASC setting that address the topic of patients' understanding of clinical information related to their recovery for an outpatient procedure or surgery (90 FR 33779). We noted that we submitted the Information Transfer PRO-PM to the CBE for endorsement review in the Fall 2023 cycle (CBE #4210) for the Hospital OQR Program, and the CBE endorsed the measure on January 29, 2024.\412\ The ASC-specific version of the Information Transfer PRO-PM is designed to use the same specifications as the Hospital OQR Program CBE-endorsed measure. We previously stated that we plan to pursue CBE endorsement for the measure's implementation in the ASC setting in a future measure endorsement cycle and we would continue to monitor implementation of the measure as part of the standard measure maintenance process.

\412\ Partnership for Quality Measurement. (2024). Fall 2023 Management of Acute and Chronic Events Meeting Summary. Available at https://p4qm.org/sites/default/files/Management%20of%20Acute%20Events%2C%20Chronic%20Disease%2C%20Surgery%2C%20and%20Behavioral%20Health/material/EM-Acute-Chronic-Events-Fall2023-Endorsement-Meeting-Summary.pdf. Accessed: April 8, 2025.

In the CY 2026 OPPS/ASC proposed rule, we proposed that the Information Transfer PRO-PM would be calculated based on PRO data collected by ASCs directly or through their authorized third-party vendors through the Information Transfer PRO-PM survey instrument \413\ distributed to patients or

their caregivers by electronic mail or text. We note that the Information Transfer PRO-PM survey is nonproprietary and free to use. We proposed that the survey be distributed within 2 to 7 days post- procedure or surgery. This timeframe minimizes the influence of variables related to the surgery or procedure, such as medications that could affect comprehension, fatigue, or acute pain, while ensuring timely reporting of patient experience related to recovery information.

\413\ A copy of the survey instrument is available at https://www.cms.gov/files/document/patient-understanding-key-information-related-recovery-after-facility-based-outpatient-procedure-or.pdf.

In the pilot testing conducted by the measure developer using a third-party vendor, patients were sent a reminder to complete the survey 7 days after receipt. The survey remained open until pilot testing was completed; the mean length of time between the procedure date to the survey response date was 65 days. Based on these findings, we proposed a 65-day window for patient response to the survey.

We proposed to adopt the Information Transfer PRO-PM as a voluntary measure for the CY 2027 and CY 2028 reporting periods followed by mandatory reporting beginning with the CY 2029 reporting period/CY 2031 payment determination. We stated we would utilize the voluntary period to monitor the implementation and operationalization of the measure. We refer readers to section XVII.C. of this final rule with comment period for a discussion of the Information Transfer PRO-PM form, manner, and timing of data submission and reporting requirements.

We invited public comments on this proposal. The following is a summary of the comments we received and our responses.

Comment: Many commenters generally supported the Information Transfer PRO-PM, stating that it is important that patients have a clear understanding of their discharge instructions to enhance recovery. Some commenters noted that this measure addresses an important measurement area, and that improving patient understanding of discharge instructions can help reduce post-procedural readmissions and mortality, which reduces waste in the healthcare system. A few commenters also agreed that PRO-PMs like this one provide valuable insights into the effectiveness of communication with patients and patient satisfaction and can help identify opportunities for improvement in perioperative care. Another commenter asserted that assessing patient experience beyond the OAS CAHPS survey can drive improvements in care transitions, reduce readmissions, and enhance outcomes. Other commenters supported CMS's decision to introduce the measure through voluntary reporting.

Response: We thank commenters for their support, including their support of a voluntary reporting period. We agree that it is important for patients to have a clear understanding of their discharge instructions to enhance recovery and reduce adverse outcomes, particularly as procedures of higher complexity move to this setting. We agree that this measure addresses an important measurement area, that this measure can provide valuable feedback to clinicians about their communication practices, and it can highlight areas of needed improvement. However, after consideration of public comments, including comments raising concerns regarding low response rates and survey fatigue, we are not finalizing the proposal to adopt the Information Transfer PRO-PM for the ASCQR Program at this time.

Comment: Some commenters supported the proposal to adopt this measure stating that adoption would be a positive step towards aligning with the Hospital OQR Program. A commenter supported CMS' proposal to utilize this measure as specified with anonymous administration, supplying potential data collection options to address the anonymity requirement while emphasizing that the measure is evidence-based, has been tested to show moderate reliability, and has been endorsed by a CBE for the hospital outpatient department setting and has been adopted for the Hospital OQR Program.

Response: We thank the commenters for their support of the measure and for their support of the survey being administered anonymously.

Comment: A commenter supported the Information Transfer PRO-PM stating there is significant variation in the transmission of information between facilities and that patients are the only source of reliable information on the effectiveness of this communication. Another commenter expressed support for including the option to allow family caregivers to provide feedback for the Information Transfer PRO- PM because of the vital role family caregivers play in patient care.

Response: We thank the commenters for their support and for noting the importance of engaging patients and caregivers for information on the effectiveness of communication of information related to their care. We agree that family caregivers play an important role in patient care.

Comment: A commenter supported the use of web-based data collection for survey administration.

Response: We thank this commenter for the support for this mode of data collection.

Comment: A commenter recommended adding questions to the Information Transfer PRO-PM that are specialty specific. For example, this commenter noted that the survey can ask patients about their experience with anesthesia or pain medications, including questions on numbness or increased pain, to provide actionable feedback and support follow-up care after outpatient procedures.

Response: We thank the commenter for their suggested updates to the Information Transfer PRO-PM. While we are not finalizing the Information Transfer PRO-PM for the ASCQR Program at this time, we note that alignment across the quality reporting programs is important to ensure that clear and effective communication of information related to recovery is addressed in every healthcare delivery setting. Accordingly, we proposed to adopt this measure in the ASCQR Program consistent with its use in the Hospital OQR Program. While there are likely to be unique aspects related to patient recovery from an ASC procedure, adopting this measure in consistent form across quality reporting programs would enable cross-setting comparisons and evaluation utilizing a national, standardized survey instrument.

Comment: A commenter did not support the Information Transfer PRO- PM and stated that since a significant portion of the proposed information to be collected is included in the discharge summary the measure information is redundant.

Response: We disagree that this measure is redundant as the purpose of the discharge summary is to meaningfully convey post-surgery instructions to patients. The Information-Transfer PRO-PM was developed to assess the patient's experience during the discharge process and their understanding of these instructions.

Comment: Some commenters recommended engaging ASCs to determine the most effective means to collect data on patient understanding of discharge instructions. One commenter stated that this measure evaluates patients' comprehension rather than the materials and care provided by facilities. Another commenter stated that the Information Transfer PRO-PM

assesses service delivery, not patient outcomes, and will not be useful in improving clinical decision-making.

Response: The Information Transfer PRO-PM is designed to evaluate facilities based on their patients' perspective of their understanding of discharge instructions and experience based on the materials supplied by facilities. We believe that this measure can provide valuable feedback to facilities on the usefulness of their materials and their method in supplying these materials. We note that a patient's lack of understanding of clinical care instructions provided after a procedure and other aspects of health literacy have been linked to poor adherence to treatment, decreased patient safety, increased return to the emergency department, and lower levels of patient satisfaction; disproportionately increased rates of such adverse effects occur to patients with limited English proficiency and patients over age 65.414 415 The Information Transfer PRO-PM addresses this important area of care coordination and offers an effective means of collecting data from patients themselves. Through this data collection, this measure can provide valuable feedback to clinicians about their communication practices and highlight areas of needed improvement in care delivery. However, after consideration of the concerns raised in public comments, we are not finalizing the proposal to adopt the Information Transfer PRO-PM for the ASCQR Program at this time.

\414\ DeSai, C., Janowiak, K., Secheli, B., et al. (2021). Empowering patients: simplifying discharge instructions. BMJ Open Quality; 10(3)001419. Available at http://doi.org/10.1136/bmjoq-2021-001419. Accessed: April 8, 2025.

\415\ Malevanchik, L., Wheeler, M., Gagliardi, K., Karliner L., & Shah, S.J. (2021). Disparities After Discharge: The Association of Limited English Proficiency and Postdischarge Patient-Reported Issues, The Joint Commission Journal on Quality and Patient Safety, 47(12):775-782. Available at https://doi.org/10.1016/j.jcjq.2021.08.013. Accessed: April 8, 2025.

Comment: Many commenters did not support adoption of the Information Transfer PRO-PM due to concerns about survey fatigue and low response rates. Several of these commenters recommended integrating the Information Transfer PRO-PM into the OAS CAHPS survey to reduce the potential for survey fatigue. A commenter noted that response rates to Federal surveys is declining as evidenced by reductions in response rates to Federal surveys in general and specifically the OAS CAHPS survey. Several commenters noted that administering two distinct surveys to the same patient cohort would require duplicative processes for identifying eligible patients, coordinating survey vendors, and managing survey distribution within overlapping timeframes. A few of these commenters stated that the OAS CAHPS survey is experiencing declining response rates over time and expressed concern that response rates for both surveys may be affected as patients may experience survey fatigue if they receive both surveys from ASCs. Another commenter requested clarification on whether multiple outreach attempts and reminders would be permitted in order to improve survey response rates.

Response: We thank the commenters for providing their concerns regarding survey fatigue and low response rates, and the suggestion to integrate the Information Transfer PRO-PM with the OAS CAHPS survey to reduce the number of surveys a patient could receive regarding their episode of care. We considered integrating questions from the Information Transfer PRO-PM survey into the OAS CAHPS survey to reduce the number of surveys a patient could receive regarding their episode of care. At that time we decided against doing so because it would necessitate changes to the specifications for administering OAS CAHPS. However, we acknowledge commenters' concerns and may consider the suggestion to combine the information transfer PRO-PM with OAS CAHPS in the future.

Research indicates that COVID-19 pandemic restrictions to in-person research greatly increased survey fatigue as researchers moved to using on-line methods 416 417 and while this affects all groups, differential effects are seen across industries \418\ and demographics.\419\ While we continue to believe that standardized patient-reported outcome measures, utilized across different payors including Federal agencies, are important to enable comparison,\420\ we also recognize that survey fatigue manifests in declining quality and quantity of survey responses and has become a significant issue in information collection. We therefore understand commenters' concern that having two patient surveys for ASCs would likely result in the potential for low response rates and survey fatigue, even if ASCs provided multiple outreach attempts. Survey fatigue may also present greater challenges for ASCs because of their smaller administrative teams and fewer dedicated resources to manage patient outreach and survey processes.

\416\ Assistant Secretary for Planning and Evaluation. (2017). Final Report Volume I: Background Paper, Declining Response Rates in Federal Surveys: Trends and Implications. Available at https:// aspe.hhs.gov/reports/final-report-volume-i-background-paper- declining-response-rates-federal-surveys-trends- implications#:~:text=Over%20the%20last%20decade%2C%20survey,of%20Data %2C%20Surveys%2C%20&%20Indicators. Accessed: October 2, 2025.

\417\ de Koning R, Egiz A, Kotecha J, et al. (2021). Survey Fatigue During the COVID-19 Pandemic: An Analysis of Neurosurgery Survey Response Rates. Frontiers in Surgery. Available at https://doi.org/10.3389/fsurg.2021.690680. Accessed: October 29, 2025. Accessed: October 29, 2025.

\418\ Brown RF, St John A, Hu, Y, Sandhu G (2024). Differential Electronic Survey Response: Does Survey Fatigue affect Everyone Equally? Journal of Surgical Research. Available at https://journalofsurgicalresearch.com/retrieve/pii/S0022480423005127. Accessed: October 29, 2025.

\419\ Porter SR, Whitcomb ME, Weitzer WH. (2004). Multiple Surveys of Students and Survey Fatigue. Chapter 5, Overcoming Survey Research Problems. Available at https://oia.unm.edu/surveys/survey-fatigue.pdf. Accessed: October 29, 2025.

\420\ What Are Patient-Reported Measures? Content last reviewed February 2025. Agency for Healthcare Research and Quality, Rockville, MD. Available at https://www.ahrq.gov/cahps/about-cahps/patient-experience/prems-proms/index.html. Accessed: October 29, 2025.

We also acknowledge that patients receiving care from ASCs may experience more survey fatigue and lower response rates than patients in other settings due to the types of care and services provided by ASCs. For example, ASCs typically handle less complex and lower-risk, same-day procedures, so patients may be less motivated to complete surveys than they would for more serious conditions. Patients at ASCs may also be less willing to complete patient surveys for facilities with which they have less ongoing engagement after discharge, as is likely with ASCs. Patients at ASCs also may undergo multiple elective procedures, so they could receive duplicative patient surveys.

In consideration of the comments received related to concerns about low response rates and survey fatigue, we are not adopting the Information Transfer PRO-PM at this time. We will provide clarification regarding multiple outreach attempts to improve survey response rates if we decide to propose the Information Transfer PRO-PM in the future.

Comment: Many commenters expressed concern that the Information Transfer PRO-PM may increase administrative burden on facilities. Some of these commenters noted the challenge of integrating surveys into clinical workflows. A few commenters stated concerns that the burden of implementing this measure is greater than its potential benefits. Several commenters expressed significant concerns with the operational and logistical challenges related to implementing an additional, separately administered patient survey because

ASCs already administer OAS CAHPS. These commenters noted that the measure's administrative tasks, including data collection and tracking, could create significant burden for facilities with existing staff shortages which would divert resources from direct patient care. A commenter stated that some ASCs are beginning to adopt the OAS CAHPS survey in preparation for mandatory reporting so the addition of another survey to the workflow would be costly and administratively burdensome at this time.

Response: We acknowledge that collecting PRO-PM data may involve more burden and initial implementation effort than some other types of quality measures. While PRO-PMs typically require facilities to integrate data collection into clinical workflows, this integration could provide an opportunity for patient-reported outcomes to inform clinical decision-making. To provide more flexibility and reduce burden, we did not propose to require facilities to collect data in a standardized way for the Information Transfer PRO-PM. However, we understand that ASCs may have less experience integrating surveys into clinical workflows, so it may still be difficult for ASCs to implement this measure. Due to this concern, and concerns that the recent increase in the number of patient surveys may contribute to survey fatigue for patients, we are not finalizing adoption of the Information Transfer PRO-PM at this time.

Comment: A few commenters stated that the Methodology Report cites evidence from inpatient and outpatient hospitals in explaining the need for this measure. These commenters stated that there is no research indicating that ASCs have similar quality concerns. A commenter explained that all ASCs provide written discharge instructions in accordance with the Conditions for Coverage, and that there is no evidence that these instructions are insufficient in the ASC setting.

Response: We understand the commenters' concern that the Methodology Report did not cite studies related to discharge instructions in the ASC setting. We note that collecting data on measures aligned across the Hospital OQR Program and the ASCQR Program allows patients to compare performance across these two settings which provide similar services. Additionally, this measure would allow patients to compare performance between ASCs on discharge instructions, an area which was determined to be important by our Patient and Family Engagement (PFE) Work Group (89 FR 94407). However, as previously stated, we are not finalizing the proposal to adopt the Information Transfer PRO-PM for the ASCQR Program at this time.

Comment: A few commenters recommended administering the Information Transfer PRO-PM in the same nine languages as the OAS CAHPS survey to ensure consistency across surveys. Several commenters recommended requiring that facilities offer the survey in the patient's preferred language, if that language is one of these nine, to ensure inclusivity.

Response: We wish to clarify that the Information Transfer PRO-PM can be completed using a translator, proxy, or caregiver, and that ASCs would have been permitted to use interpretation and translation services in order to ensure that ASCs were administering the survey in the patient's preferred language. Although we are not finalizing adoption of the Information Transfer PRO-PM, we appreciate the commenters' recommendations and will consider available language options for the Information Transfer PRO-PM if we decide to propose this measure in the future.

Comment: Several commenters expressed doubts about the applicability of the measure as it has not been tested in the ASC setting. Some of these commenters recommended site-specific testing in the ASC setting before inclusion in the ASCQR Program. A commenter stated that the measure developer acknowledged the potential need to modify the measure for use among ASCs and recommended evaluating it for needed modifications before adoption. For example, a commenter noted that the survey introduction uses the word “hospital” twice and expressed concern that, even if the name of the facility is correct, this could cause patients to question the legitimacy or applicability of the survey. This commenter stated that measures should be fully tested in the setting for which they are being proposed before being adopted (even as voluntary measures) into quality reporting programs. A commenter recommended piloting the measure in an upcoming CMS Innovation Center (CMMI) Model as a means of testing the measure's feasibility for widespread implementation. A commenter requested clarification regarding whether survey response rates had been tested when both the OAS CAHPS survey and the Information Transfer PRO-PM survey are administered to the same patient population.

Response: We believe that the measure is applicable to the ASC setting because improving patient understanding of discharge information is an important part of providing quality care across all care settings. Historically discharge information is provided in written form after surgery because the effects of anesthesia and pain medication may impair the patient's ability to retain information. However, we understand commenters' concerns related to feasibility of implementing this measure without tailoring it to the ASC setting due to lack of testing in the ASC setting. We note that we are not finalizing this measure at this time, and that we will review the measure specifications for applicability to ASCs and will update language as necessary if we decide to propose this measure in the future. We will consider additional testing for the Information Transfer PRO-PM if we decide to propose this measure in the future. If we do conduct additional testing in the future, results of testing would reflect administration of the Information-Transfer PRO-PM and OAS CAHPS because OAS CAHPS is now mandatory for ASCs.

Comment: A few commenters expressed concern regarding potential conflicts between the requirements for the Information Transfer PRO-PM survey and the OAS CAHPS guidelines. A few commenters specifically mentioned that the OAS CAHPS guidelines recommend selecting the OAS CAHPS sample prior to any other survey and not including the same patients in more than one survey to ensure the highest response rates possible. A few commenters stated that the OAS CAHPS guidelines indicate that ASCs must coordinate with the OAS CAHPS Survey Coordination Team if they are conducting more than one Federally sponsored survey and that introduction of the Information Transfer PRO- PM would require all ASCs to coordinate with this team. These commenters expressed concern that the requirements for this survey contradict the goal of ensuring the highest response rate possible for the OAS CAHPS survey since the Information Transfer PRO-PM survey would be distributed before the OAS CAHPS survey, as most patients do not receive the OAS CAHPS survey until five to six weeks after the procedure. A commenter expressed concern that patients may not appreciate the distinction between the two surveys, leading them to discard the second survey. Some commenters recommended developing a coordinated administration plan that ensures patients do not receive more than one survey for the same encounter.

Response: We thank commenters for raising concerns regarding possible

conflicts with the requirements for the Information Transfer PRO-PM survey and the OAS CAHPS guidelines.

Regarding the concern that ASCs must coordinate with the OAS CAHPS Survey Coordination team, we wish to clarify that the OAS CAHPS FAQ document describes this as a recommendation and not a requirement, and note that it only would apply if more than one survey vendor was used or if the surveys were being self-administered.\421\ We acknowledge that the timing and order of administering those surveys may impact the likelihood of patients responding to each survey. Additionally, we understand that administering the Information Transfer PRO-PM to every patient, not to a subset or sample of patients, would necessarily lead to some patients receiving multiple surveys. However, we believe that both surveys provide valuable insights into different aspects of a patient's experience. While we are not finalizing the Information Transfer PRO-PM in this final rule, we will take these comments into consideration if we propose the measure in the future.

\421\ OAS CAHPS. Frequently Asked Questions for Hospitals and ASCs OAS CAHPS[supreg]. OAS CAHPS. Available at https://oascahps.org/OAS_Facility_FAQs.docx. Accessed: October 14, 2025.

Comment: A few commenters noted that the denominator cohort for the Information Transfer PRO-PM is different from the denominator cohort for OAS CAHPS, and that as a result, ASCs would need to separately determine patient eligibility for each survey, which could result in onerous processes related to survey administration. A commenter stated that the OAS CAHPS cohort includes codes and exclusions that are not replicated in the Information Transfer PRO-PM. This commenter recommended aligning the denominator cohorts and identifying a mechanism to ensure future standardization of the two surveys to reduce the burden of maintaining two different processes. Another commenter requested clarification regarding which survey, the OAS CAHPS survey or the Information Transfer PRO-PM survey, should be administered to patients first.

Response: We appreciate commenters' recommendation to align the Information Transfer PRO-PM and OAS CAHPS cohorts and to minimize the burden of administering the two surveys. During development of the Information Transfer PRO-PM, we considered incorporating the survey instrument into the OAS CAHPS survey to reduce the number of surveys a patient could receive regarding their episode of care. However, we decided against doing so at that time as the specifications for administering the OAS CAHPS (such as the survey timing, allowing multiple submission modes and requiring a CMS-approved vendor) do not align with the Information Transfer PRO-PM. The PRMR Hospital Recommendation Group recommended the Information Transfer PRO-PM with conditions for the Hospital OQR Program; the condition was to administer the survey at the time of the surgery or procedure so that there is no conflict with other measured pain and function outcomes to improve response rates. We considered this condition and determined that a survey administration window of 2 to 7 days post-procedure provides the necessary balance between allowing patients sufficient time for recovery and comprehension of the Information Transfer PRO-PM survey questions, while also mitigating potential overlap with the OAS CAHPS survey, which begins on the first day post-procedure and includes a reminder at 14 days. Therefore, to the commenter's question on which survey should be administered first under our proposal to adopt the Information Transfer PRO-PM, based on the survey timing guidelines mentioned above, the OAS CAHPS survey should be administered first (that is, first day post-procedure), followed by the Information Transfer PRO-PM survey at any point from 2 to 7 days post-procedure. Currently, there has been no testing measuring survey response rates when both surveys are administered to the same patient population. While we are not finalizing adoption of the Information Transfer PRO-PM in this final rule, we will take these comments into consideration if we propose the measure in the future.

Comment: A commenter requested clarification on when data submission specifications would be provided to vendors and whether there would be a point of contact for questions regarding those specifications. A commenter recommended that CMS provide materials such as technical guidance and standardized tools to assist with reporting.

Response: Data submission specifications for the reporting of this measure are available in the Hospital OQR Program Specifications Manual and would have applied to the ASCQR Program if the measure had been adopted as proposed.\422\ Additionally, vendors may submit inquiries for the Information Transfer PRO-PM through the ServiceNow website. However, as previously stated, we are not finalizing the proposal to adopt the Information Transfer PRO-PM for the ASCQR Program at this time.

\422\ Centers for Medicare & Medicaid Services. QualityNet. Available at https://qualitynet.cms.gov/files/6830945005ca4cea73650e74?filename=OQR_v19.0_SpecsManual_2026.pdf. Accessed: October 6, 2025.

Comment: A commenter requested clarification on how responses of “Does Not Apply” would be treated in scoring and whether partially completed surveys would contribute to measure results. Another commenter requested clarification regarding whether facilities would receive domain-level feedback or only a composite score.

Response: Individual scores are calculated for each respondent by taking the sum of items for which the respondent gave the most positive response (either, “Yes” or “Very Clear”) and dividing by the number of items the respondent deemed applicable to their procedure or surgery. Applicable items are calculated by subtracting the sum of items for which the respondent selected “Does not apply” from the total number of survey items (nine). Only fully completed surveys would be included in the measure calculation.\423\ If a facility administers the Information Transfer PRO-PM survey, they would be able to calculate domain level or composite results. If a facility uses a third-party to administer the survey, the granularity of data available to the facility would depend on the contract with their selected vendor. However, as previously explained, we are not finalizing the proposal to adopt the Information Transfer PRO-PM for the ASCQR Program at this time.

\423\ Partnership for Quality Measurement. Submission Tool and Repository Measure Database. Available at https://p4qm.org/measures/4210. Accessed: April 8, 2025.

Comment: Some commenters had concerns with the measure specifications. These commenters recommended that measure scores be adjusted to account for patient factors beyond the control of the facility such as age, education, surgery type, time between surgery and survey response, overall physical and mental health, health literacy, and language barriers. Some of these commenters recommended that other survey factors such as non-response rates, a minimum response-rate threshold, and annual review to identify any potential bias be considered. A commenter stated that combining the Information Transfer PRO-PM survey with the OAS CAHPS survey would allow data from both surveys to be adjusted in the same manner.

Response: We understand commenters' concerns about measure

specifications with regard to patient factors beyond the control of the facility. We note the measure developer conducted testing to examine the need for risk adjustment to the measure for a set of factors such as patients self-reported health status, history of procedures, age, and education, and found there was not a significant relationship between the adjusted and unadjusted measure scores. Therefore, given the lack of a significant relationship between adjusted and unadjusted scores, there was empirical evidence to support an unadjusted measure and that providers and facilities should be able to provide clear, personalized instruction to all patients about their recovery from a procedure or surgery.\424\ Additional details regarding measure testing and measure methodology, are available on the QualityNet website: https://qualitynet.cms.gov/outpatient/measures/PRO-PM/methodology. However, as previously stated, we are not finalizing the proposal to adopt the Information Transfer PRO-PM for the ASCQR Program at this time.

\424\ Centers for Medicare & Medicaid Services. (April 2024). Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure (PRO-PM). Available at https://qualitynet.cms.gov/outpatient/measures/PRO-PM/methodology. Accessed: November 12, 2025.

Comment: A few commenters expressed concern about the operational feasibility of the survey timing. Specifically, some commenters expressed concern about issuing survey invitations in the period 2 to 7 days post-procedure. These commenters stated that because of coding practices it may not be feasible to assign CPT-4 or HCPCS Level II codes within this timeframe as well as submit patient files to vendors with sufficient time for the vendor to process files, confirm patient eligibility, and issue invitations. A commenter recommended updating the eligibility definition to rely on data elements available in near real time (for example, use of anesthesia or sedation) or extending the timeline for survey administration. A commenter expressed concern about the 65-day timeline for patients to respond to the survey. The commenter referenced CMS' statement that in the pilot the mean length of time between the procedure date and the survey response date was 65 days and stated that the 65-day period was actually the amount of time that it took to send the survey invitation.

Response: We appreciate commenters' feedback regarding the feasibility of the proposed survey administration timeline, including concerns about the period for issuing invitations (2 to 7 days post- procedure) and the overall survey response window. We acknowledge commenters' operational concerns related to the availability of CPT-4 and HCPCS Level II codes and the ability of facilities and their vendors to identify eligible patients and submit files within the proposed timeframe. The proposed 2- to 7-day invitation window was selected to promote timely contact with patients following the clinical encounter and to minimize recall bias by focusing responses on the recent episode of care. These operational timing parameters were informed by the pilot testing conducted by the measure developer.

With respect to the 65-day observation highlighted by commenters, we clarify that during pilot testing, the survey remained open until sufficient response was attained with the mean interval between the procedure date and the survey response date being 65 days, or approximately two months. We identified this finding as the basis for proposing a 65-day response window to allow sufficient time for patients who are sent an invitation and for non-responders to receive reminders and to submit completed surveys.

At this time, we believe the timing parameters for invitation issuance and the proposed 65-day response window are appropriate to support valid, comparable measurement across facilities while balancing operational feasibility. However, we are not finalizing the Information Transfer PRO-PM for the ASCQR Program at this time.

Comment: A commenter expressed concern that limiting survey administration to email and text communications may affect representativeness and data quality because patients who have limited internet access may not be included in the survey. A commenter expressed concern about limiting access to email and text communications because people are becoming more reluctant to complete surveys due to concerns about data privacy, specifically associated with emails and text communications from unknown or unverified entities. Another commenter stated that the burden is more pronounced for ASCs specializing in ophthalmology, as their ophthalmology patients cannot easily check their emails or text messages due to limited vision.

Response: We appreciate the commenters' concerns about representativeness and data quality as well as the potential impact of this measure to ASCs specializing in ophthalmology. The measure developer did not identify systemic challenges in reaching patients through email or text message. Additionally, as distribution of the survey occurs 2 to 7 days after the procedure, the patient has up to 65 days to respond, and the survey can be completed using a translator, proxy, or caregiver, the influence of post-surgical variables can be minimized.

However, we note that we are not finalizing adoption of this measure at this time and may re-evaluate available survey modalities if we propose the measure in the future.

Comment: A commenter expressed concern that the measure fails to exclude certain patients, potentially violating the Telephone Consumer Protection Act (TCPA) and the Health Insurance Portability and Accountability Act (HIPAA). This commenter proposed excluding: (1) patients without email or text messaging access, (2) patients who have not given (or have withdrawn) prior consent for text message survey invitations (to comply with the TCPA), and (3) patients who requested confidential admission (to adhere to HIPAA). A commenter expressed concern that some ASCs' legal teams interpret a patient opting-out of text survey invitations as opting-out of all text-based communications. This commenter recommended that prior to adopting the Information Transfer PRO-PM, CMS provide guidance on how to allow patients to opt- out of the survey without opting out of important patient communications, such as appointment reminders.

Response: We thank the commenter for expressing these concerns regarding the TPCA and HIPAA as they relate to survey administration. The TPCA establishes rules for how surveys can be administered via phone. If this measure were adopted, facilities and their vendors would need to comply with TCPA regulations to avoid penalties and maintain patient privacy. These requirements are in regard to prior consent, limitations on the use of automatic dialers, and restrictions on artificial or prerecorded messages when contacting patients by phone for the Information Transfer PRO-PM. ASCs would need to work with their legal teams to determine opt-in or opt-out language that clearly indicates the patient's communication preferences. However, we reiterate that we are not finalizing the proposal to adopt the Information Transfer PRO-PM for the ASCQR Program at this time.

Comment: A few commenters stated that the requirement for anonymity limits their ability to use the survey data to investigate any issues identified and

to develop targeted action plans and quality improvement efforts, which defeats the purpose of the measure. A commenter stated that the measure has not been tested with a self-administration option and recommended testing self-administration and resolving barriers prior to adopting this measure. A few commenters requested guidance on how facilities could administer the survey anonymously without working with an outside vendor. A commenter expressed concern about the survey's current framing around anonymity as the instrument introduction informs patients that their responses are “completely anonymous,” yet facilities must necessarily use protected health information to identify and contact eligible patients, creating at least a temporary link between patient identity and survey responses. The commenter stated that this promise of total anonymity could increase distrust for patients, whereas stating that the responses would be confidential both aligns with patients' understanding of how healthcare organizations handle their most sensitive data and also aligns with other CMS patient surveys.

Response: We thank the commenters for their input. We agree that anonymity places constraints on use of the measure data which must be balanced with confidentiality concerns. We acknowledge that there are both advantages and disadvantages to maintaining anonymity in patient surveys. Anonymity may encourage patients to provide more candid and reliable feedback about their experiences, which can enhance the validity of the information collected. However, as commenters noted, anonymity can limit the ability of facilities to conduct targeted follow-up or quality improvement activities and may, in some cases, contribute to patient distrust if the anonymity promise is not clearly explained. We appreciate the commenters' insights on these challenges and we agree that the balance between protecting patient privacy and enabling meaningful quality improvement is important.

The survey instrument notes that patient responses are anonymous and that neither the patient's name nor any other identifying information will be shared with their clinician or facility. We recognize that vendors and facilities must use protected health information (such as patient names, contact information, and encounter dates) to invite and remind patients to complete the electronic survey during the administration process. Consistent with prior CMS surveys, such as OAS CAHPS, the intent of this Information Transfer PRO-PM's anonymity language is to indicate that individual patient responses will not be reported or publicly displayed with patient identifiers and will be handled in a manner that protects patient privacy.

When a facility administers the survey directly (without a vendor), it may leverage existing survey tools that include features that protect patient anonymity. Facilities administering the survey themselves can follow-up with all eligible patients throughout the 65- day response window based on the procedure date, rather than the survey administration date. Where vendors are used, we expect both vendors and facilities to comply with all applicable privacy protections and business-associate agreements under HIPAA. They must also meet any minimum business and quality requirements outlined in CMS guidance for vendor administered surveys. If we propose to adopt the Information Transfer PRO-PM in the future, we would provide guidance to support facilities that wish to administer surveys internally or without vendor involvement.

We acknowledge that the phrase “completely anonymous” may be interpreted to mean that no possible link to the identity of the respondent ever exists, which is not operationally feasible where contact information must be used to invite and remind patients to complete the survey. To reduce possible confusion and patient distrust, and to align with language used in other CMS patient surveys, we will consider revising the instrument introduction and associated text to clarify that: (i) contact information is used only to invite and remind eligible patients, (ii) individual survey responses will be protected and will not be reported to CMS or published with personal identifiers, and (iii) aggregate or de-identified data will be used for measure calculation and reporting. Although we are not finalizing adoption of this measure at this time we note that this clarification would be reflected in our operational guidance for implementation if this measure is considered for the ASCQR Program in the future. We will also consider including this clarification in our operational guidance for implementation in the Hospital OQR Program.

We note that the proposed voluntary reporting period was also intended to allow for refinement of mode-of-administration recommendations and to identify barriers to self-administration through operational experience. We will consider including additional guidance or flexibilities in this area in future iterations of the measure. Additionally, we recognize that challenges with recruiting ASCs to participate in testing during initial measure development limited opportunities to fully evaluate self-administration approaches, and similar challenges could resurface if we pursue additional testing in this area in the future.

Comment: A commenter stated that facilities already work with Patient and Family Advisory Councils to improve patient communications and that these engagements are more likely to provide meaningful improvements than an anonymous survey which does not allow for follow- up.

Response: We agree that Patient and Family Advisory Councils are a valuable resource, and encourage facilities to engage with these councils to improve their discharge planning processes and overall patient communication.

Comment: A few commenters expressed concern regarding the implementation timeline of the Information Transfer PRO-PM and recommended that CMS delay implementation and extend the use of voluntary reporting periods. A commenter recommended that CMS monitor ASC feedback during the voluntary reporting period to ensure ASCs do not face widespread technical or operational challenges which would require postponing mandatory implementation.

Response: We understand commenters' concern regarding the timeline for the Information Transfer PRO-PM, and we note that we are not finalizing adoption of this measure in the ASCQR Program at this time.

Comment: A commenter stated that when the measure underwent CBE review for the hospital outpatient setting the committee found that the measure did not meet requirements for scientific acceptability, specifically that the sample was too small to report reliability by decile and that the results for validity testing were non-significant.

Response: We acknowledge the commenter's concern regarding the measure's scientific acceptability, but note that the measure developer conducted pilot testing in 26 HOPDs across five states and demonstrated that the measure is both reliable and

meaningful.\425\ Reliability of the measure was assessed with the Cronbach alpha score \426\ to determine whether the survey questions reliably measure the same underlying characteristic, that is, patients' assessment of the clarity and applicability of recovery instruction. The Cronbach alpha score indicated that the survey items are reliable.\427\ The measure developer also found that facility performance scores in the pilot study demonstrated moderate reliability based on a signal-to-noise ratio. This analysis estimated variance across facilities and measured facility-specific standard errors to determine the extent to which variance in facility scores can be attributed to variance in actual performance.\428\ More information about the testing, feasibility, scientific acceptability, meaningfulness, and validity of the Information Transfer PRO-PM for the HOPD setting is available at https://p4qm.org/measures/4210.

\425\ Centers for Medicare & Medicaid Services. (April 2024). Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure. Available at https://www.cms.gov/files/document/patient-understanding-key-information-related-recovery-after-facility-based-outpatient-procedure-or.pdf. Accessed: April 29, 2025.

\426\ For more information on what the Cronbach alpha score determines and how it is used, we refer readers to: Tavakol, M., & Dennick, R. (2011). Making sense of Cronbach's alpha. Int J Med Educ. 27;2: 53-55. Available at https://www.ijme.net/archive/2/cronbachs-alpha.pdf. Accessed: April 30, 2025.

\427\ Centers for Medicare & Medicaid Services. (April 2024). Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure. Available at https://www.cms.gov/files/document/patient-understanding-key-information-related-recovery-after-facility-based-outpatient-procedure-or.pdf. Accessed: April 29, 2025.

\428\ Centers for Medicare & Medicaid Services. (April 2024). Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure. Available at https://www.cms.gov/files/document/patient-understanding-key-information-related-recovery-after-facility-based-outpatient-procedure-or.pdf. Accessed: April 29, 2025.

During measure testing, the developer conducted extensive outreach for testing partners, however, ASCs were unavailable at the time of the testing period due to competing demands of implementing other PRO-PMs. The measure developer completed two pilot studies in the HOPD setting. The average annual case volume of an ASC is 4,714, indicating it would take a minimum of three months to meet the minimum requirement of respondents. Given the similar patient or caregiver interactions and goals in ASCs and HOPDs, we expect testing results to have similar reliability.

Comment: A commenter noted that this measure has not met statutory requirements for inclusion in the ASCQR Program due to not being endorsed by a Consensus-Based Entity (CBE) for use in the ASC setting.

Response: We thank the commenter for their observation that the measure has not been endorsed by the CBE for use in the ASC setting. We recognize the value of measures undergoing review for potential CBE endorsement and of measure endorsement specific to care setting. We note that the Information Transfer PRO-PM went through the rigorous measure development lifecycle outlined at the CMS Measures Management System website \429\ which includes measure testing and reliability analysis. Furthermore, for the Hospital OQR and ASCQR Programs, we note that section 1833(t)(17) of the Act does not require that each measure we adopt be CBE-endorsed (76 FR 74494), but states that the Hospital OQR and ASCQR Programs, to the extent feasible and practicable, shall include measures set forth by one or more national consensus building entities. We reviewed measures endorsed by consensus organizations and were unable to identify any other measures on this topic endorsed by a consensus organization in the ASC setting, so the inclusion of an endorsed measure is not feasible or practicable. Section 1833(t)(17)(C)(i) of the Act also requires measures included in the Hospital OQR and ASCQR Programs to reflect consensus among affected parties. As we have stated in previous rulemaking (75 FR 72064 and 76 FR 74494), consensus among affected parties can be reflected in ways other than CBE endorsement, including through the measure development process, through broad acceptance and use of the measure(s), and through public comment. However, in light of the significant number of negative public comments received during the comment period opposing the adoption of this measure for the ASCQR Program, we have concerns that there may be a lack of consensus among interested parties. These concerns reflect an additional reason we are not finalizing this measure at this time.

\429\ CMS. Measure Management Lifecycle Overview. Available at https://mmshub.cms.gov/blueprint-measure-lifecycle-overview. Accessed: October 5, 2025.

Comment: A commenter stated that the requirement for consensus has not been met through broad acceptance of the measure by ASCs. The commenter stated that the ASC representative on the TEP did not support the use of the measure in the ASC setting and that ASC interested parties have not supported the measure in public comments.

Response: Section 1833(t)(17)(C)(i) of the Act requires measures included in the Hospital OQR and ASCQR Programs to reflect consensus among affected parties. As we have stated in previous rulemaking, consensus among affected parties can be reflected in various ways, including through the measure development process, through broad acceptance and use of the measure(s), and through public comment.

As previously stated, we have concerns regarding a potential lack of consensus among interested parties, given the significant number of negative public comments received during the comment period opposing the adoption of this measure for the ASCQR Program. This concern represents an additional reason we are not finalizing this measure at this time.

After consideration of public comments, we are not finalizing adoption of the Information Transfer PRO-PM for the ASCQR Program at this time. 2. Summary of Previously Finalized and Newly Finalized ASCQR Program Measure Set for CY 2026 to CY 2031 Payment Determinations

Table 140 summarizes the previously finalized and newly finalized ASCQR Program measure set for the CY 2026 to CY 2031 payment determinations. Table 140 reflects the removal of the FCHE, Screening for SDOH, Screen Positive Rate for SDOH, and the COVID-19 Vaccination Coverage Among HCP measures as discussed in section XIV.C., we note that we are not finalizing the addition of the Information Transfer PRO-PM as discussed in section XVII.B.1. of this final rule with comment period. BILLING CODE 4120-01-P

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BILLING CODE 4120-01-C

We refer readers to the QualityNet website at https://qualitynet.cms.gov/asc/ascqr for additional information on the reporting periods and submission deadlines for each measure finalized and proposed in the ASCQR Program. 3. ASCQR Program Measures and Topics for Future Consideration

We refer readers to section XIV.B. of this final rule with comment period for information regarding our cross-program

Request for Information on measure concepts regarding well-being and nutrition for consideration in the ASCQR Program.

In the CY 2026 OPPS/ASC proposed rule, we proposed to establish data submission and reporting requirements for Patient-Reported Outcome-Based Performance Measures (PRO-PMs) for the ASCQR Program, including for the proposed Information Transfer PRO-PM (90 FR 33782). 1. Data Submission and Reporting Requirements for PRO-PMs a. Data Submission Requirement for PRO-PMs

In the CY 2024 OPPS/ASC final rule with comment period (88 FR 82041), we finalized that for the Total Hip Arthroplasty and/or Total Knee Arthroplasty PRO-PM, ASCs must use the Hospital Quality Reporting (HQR) system for data submission as specified for a PRO-PM. In the CY 2026 OPPS/ASC proposed rule, we proposed to apply this submission method to PRO-PMs generally, including the Information Transfer PRO-PM (90 FR 33782). Specifically, we proposed that ASCs must use the HQR system for data submission for any PRO-PM that we adopt for the ASCQR Program measure set. ASCs may choose to: (1) directly submit their PRO- PM data to CMS using the HQR system; or (2) utilize a third-party entity, such as a vendor or registry, to submit their data using the HQR system. The HQR system allows for data submission using multiple file formats (such as .CSV and .XML) or a manual data entry option, allowing ASCs additional flexibility in data submission. b. Data Submission and Reporting Requirements for the Information Transfer PRO-PM

In the CY 2026 OPPS/ASC proposed rule, we discussed the proposed adoption of the Information Transfer PRO-PM beginning with voluntary reporting for the CY 2027 and CY 2028 reporting periods followed by mandatory reporting beginning with the CY 2029 reporting period/CY 2031 payment determination (90 FR 33776 through 33779). We proposed that the reporting period for this measure would include data collection for procedures performed from January 1 through and including December 31 of the year that is two years prior to the applicable payment determination year. Therefore, ASCs would attribute patient survey responses to the CY reporting period during which the patient's procedure was completed. For example, if a patient undergoes a procedure on December 20, 2027, and their survey response is received on January 4, 2028, that response would be attributed to the CY 2027 reporting period. In the CY 2026 OPPS/ASC proposed rule we proposed a 65-day response window for collecting patient survey responses (90 FR 33776 through 33779). Under this 65-day response window policy, ASCs may collect survey responses for a reporting period as late as March of the year preceding the applicable payment determination year.

We proposed to require ASCs to submit their Information Transfer PRO-PM data in aggregate numerators and denominators by May 15 of the year prior to the applicable payment determination year in the HQR system. As codified at 42 CFR 416.310(f), all deadlines occurring on a Saturday, Sunday, or legal holiday, or on any other day, all or part of which is declared to be a non-workday for Federal employees by statute or Executive Order would be extended to the first business day thereafter. For example, for the first voluntary reporting period, data collected for the Information Transfer PRO-PM from surgical procedures performed January 1, 2027, through December 31, 2027, would be submitted to CMS's HQR system by May 15, 2028. For the first mandatory reporting period, data collected for the Information Transfer PRO-PM from surgical procedures performed January 1, 2029, through December 31, 2029, would be submitted to CMS's HQR system by May 15, 2030, for the CY 2031 payment determination.

We proposed to require ASCs to offer all patients meeting the measure's denominator specifications the opportunity to complete the survey and to report on all completed surveys received. For ASCs that anticipate receiving more than 200 completed surveys, these facilities would have the option to either: (1) survey and report data on their entire eligible Information Transfer PRO-PM patient population, or (2) randomly sample their eligible Information Transfer PRO-PM patient population to collect and report data from 200 completed surveys. Thus, to reduce burden, facilities with large patient populations would have the choice to randomly sample a sufficient number of patients to yield at least 200 completed surveys in a reporting period. ASCs that are unable to collect 200 completed surveys would not be able to perform random sampling and would instead be required to submit data on survey responses from all completed surveys received.

A minimum random sample size of 200 completed surveys would ensure the reliability of the measure, consistent with what is required for the OAS CAHPS measure for ASCs (86 FR 63908 through 63909). We note that under the Hospital OQR Program, a minimum sample size of 300 is required for the Information Transfer PRO-PM as this is a recommended minimum sample size for a population of 1,500 to provide a 95 percent confidence interval for a population of over 10,000; this is also generally accepted as a minimum sample size for stable population estimates.430 431 However, as ASCs are expected to have less varied populations, we believe the sample size of 200 completed surveys, as determined to be sufficient for the OAS CAHPS survey, is appropriate. The 200 surveys would provide the appropriate balance of ensuring sufficient confidence in the results of the Information Transfer PRO-PM survey, while reducing the overall burden of the survey for facilities with large patient populations.

\430\ Ahmad, H., & Halim, H. (2017). Determining Sample Size for Research Activities. Selangor Business Review, 2(1), 20-34. Available at https://sbr.journals.unisel.edu.my/index.php/sbr/article/view/12. Accessed: April 8, 2025.

\431\ Voorhis, C., & Morgan, B. (2007). Understanding Power and Rules of Thumb for Determining Sample Size. Tutorials in Quantitative Methods for Psychology. 3(2), 43-50. Available at www.doi.org/10.20982/tqmp.03.2.p043. Accessed: April 8, 2025.

We invited public comments on this proposal.

Comment: A commenter expressed concern regarding the measure's feasibility as CMS requires a minimum random sample size of 200 completed surveys and asked for clarification regarding the proposal for the minimum random sample size. Another commenter expressed concern that lower-volume facilities would be unable to meet the minimum of 300 survey responses. A commenter noted that extrapolation from the results of the 8-month pilot test in the hospital outpatient department shows that only 38 percent of facilities would have reached the threshold of 200 completed surveys over the course of a year. The commenter stated that this indicates that the threshold of 200 completed surveys is not feasible.

Response: Under the Hospital OQR Program, a minimum random sample size of 300 completed surveys is recommended for a population of 1,500 to provide a 95 percent confidence interval and a 90 percent confidence interval for a population of over 10,000

by reducing the standard error (89 FR 94420 through 954421). As ASCs are expected to have less varied populations, we determined the sample size of 200 completed surveys, which aligns with the sample size for the OAS CAHPS survey, is appropriate. The 200 surveys would provide the appropriate balance of ensuring sufficient confidence in the results of the Information Transfer PRO-PM, while reducing the overall burden of the survey for facilities with large patient populations. We note that we would require data to be submitted on all completed surveys for ASCs unable to achieve 200 completed surveys. However, as discussed in section XVII.B.1. of this final rule with comment period, we are not finalizing our proposal to adopt the Information Transfer PRO-PM into the ASCQR Program measure set at this time and therefore we are also not finalizing our proposed data submission and reporting requirements to be applied to PRO-PMs generally.

Comment: A commenter requested clarification on the apparent discrepancy between permitting sampling when sending the Information Transfer PRO-PM survey and the requirement to offer all patients meeting the measure's denominator specifications the opportunity to complete the survey.

Response: If the Information Transfer PRO-PM had been adopted as proposed, we would have required that all patients that meet the measure's denominator specifications have the opportunity to complete the survey. For facilities that received more than 200 completed surveys, the facility would have the option to randomly sample from these surveys for reporting the measure results. The 200 surveys would provide the appropriate balance of ensuring sufficient confidence in the results of the Information Transfer PRO-PM survey, while reducing the overall burden of the survey for facilities with large patient populations.\432\ We note that all questions on the survey must be completed to meet the 200-survey minimum. Partially completed surveys should not be counted towards the 200-survey minimum.

\432\ Malevanchik L., Wheeler M., Gagliardi K., Karliner L., Shah S.J. (2021). Disparities After Discharge: The Association of Limited English Proficiency and Postdischarge Patient-Reported Issues, The Issues, The Joint Commission Journal on Quality and Patient Safety, 47(12):775-782. Available at https://doi.org/10.1016/j.jcjq.2021.08.013. Accessed: October 29, 2025.

After consideration of public comments, we are not finalizing adoption of the Information Transfer PRO-PM for the ASCQR Program at this time, or our proposed data submission and reporting requirements to be applied to PRO-PMs generally. 2. ASCQR Program Extraordinary Circumstances Exception (ECE) Policy

We refer readers to section XIV.D. of this final rule with comment period for our cross-program policy to codify updates to the ECE policy for the ASCQR Program.