Hospital Outpatient Quality Reporting

Program Background
CMS Quality Initiatives
Background
The Medicare Improvements and Extension Act under Division B of Title I of the Tax Relief and Health
Care Act (MIEA-TRHCA) of 2006 (Pub. L. 109–432), enacted on December 20, 2006 authorized The
Centers for Medicare & Medicaid Services (CMS) to have a program under which hospitals may report data
on the quality of outpatient care using standardized measures to receive the full annual payment update
(APU) under the Outpatient Prospective Payment System (OPPS). The program established under the
Calendar Year (CY) 2009 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center (ASC)
Payment Systems Final Rule and supported by this manual is the Hospital Outpatient Quality Reporting
(OQR) Program, formerly known as the Hospital Outpatient Quality Data Reporting Program (HOP QDRP).
Quality Reporting
The Hospital OQR Program seeks to collect data and publicly report on quality metrics so that the
information is available to support consumer decision-making and provider improvements regarding the
quality and efficiency of care in this setting.

Related Activities
Measure Development

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Sections 1833(i)(7)(B) and 1833(t)(17)(C)(i) of the Act requires the Secretary to develop measures
appropriate for the measurement of the quality of care furnished by hospitals in outpatient settings, and that
measures reflect consensus among affected parties. Measures are not required to be endorsed by any national
consensus-based entity. Consensus among affected parties can be achieved in other ways, including input
from the consensus-based entity’s measure review process, measure development process, through broad
acceptance and use of the measure(s), and through public comment.

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Measures Management System
The Measures Management System (MMS) is a standardized system for developing and maintaining the
quality measures used in various CMS initiatives and programs. MMS also supports quality-related activities
across the agency. Quality measures are tools that help improve the quality of healthcare through an approach
that is consistent and accountable. The primary goals of the MMS are to:
• Provide support and guidance to measure developers to help them produce high caliber healthcare
quality measures, and
• Educate and inform interested parties to promote involvement in and awareness of the Measure
Lifecycle.
Electronic Clinical Quality Measures (eCQM)
Beginning with Calendar Year (CY) 2023 reporting period, hospitals were provided the opportunity to
voluntarily submit data for OP-40: ST-elevation myocardial infarction (STEMI), an electronic clinical
quality measure (eCQM), in the Hospital OQR program. Beginning with CY 2024 reporting period,
hospitals will be required to report one self-selected calendar quarter of data. For CY 2025 reporting period
the requirement increases to two self-selected calendar quarters of data, followed by three required quarters
in CY 2026 and all four quarters beginning with CY 2027 reporting period and subsequent years. For more
information on the adoption of OP-40 eCQM, please refer to the CY 2022 OPPS/ASC Final Rule, beginning
on page 63837, published in the Federal Register.
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Hospital OQR Specifications Manual
Encounter dates 01-01-26 (1Q26) through 12-31-26 (4Q26) v19.0
CPT® only copyright 2025 American Medical Association. All rights reserved.

Refer to the Technical Specifications and Resources for the CMS Quality Reporting Document Architecture
(QRDA) Category I Implementation Guide for the applicable reporting period, measure specification
information, and program resources to support successful eCQM reporting on the eCQI Resource Center.

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Outpatient and Ambulatory Surgery Consumer Assessment (OAS CAHPS)
The OAS CAHPS initiative was developed as a patient-experience-of-care survey for patients who had
surgery or a procedure at a hospital outpatient department (HOPD) or an ambulatory surgery center (ASC).
Prior to OAS CAHPS, there was no standardized survey instrument to assess patient experience with
outpatient surgical care received at HOPDs and ASCs. Hospitals contract with a CMS-approved OAS
CAHPS Survey vendor to conduct the survey. A list of approved survey vendors is available at the following
link: https://oascahps.org/General-Information/Approved-Survey-Vendors.
Beginning with CY 2023 reporting period, hospitals were provided the opportunity to voluntarily submit data
for the OAS CAHPS survey.
Beginning with CY 2024 reporting period, hospitals will be required to report quarterly data by the
submission deadlines provided on the OAS CAHPS website.
Paperwork Reduction Act (PRA) Disclosure
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection
of information unless it displays a valid Office of Management and Business (OMB) control number. The
valid OMB control number for this information collection is 0938-1109. The time required to complete this
information collection is estimated to average 15 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, MD 21244-1650.

Hospital OQR Specifications Manual
Encounter dates 01-01-26 (1Q26) through 12-31-26 (4Q26) v19.0
CPT® only copyright 2025 American Medical Association. All rights reserved.

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