During a recent Ambulatory Surgical Center Quality Reporting (ASCQR) Program webinar on the OAS CAHPS Survey Measure, the Outpatient Quality Reporting Support Team addressed several areas of confusion surrounding Extraordinary Circumstances Exceptions (ECEs) and Participation Exemption Requests (PERs). Understanding these requirements can help ASCs remain compliant and avoid Medicare payment penalties.
Here are five common misconceptions about OAS CAHPS exemption eligibility and reporting requirements.
1. A Staffing Issue Is Not an Extraordinary Event
Extraordinary Circumstances Exceptions (ECEs) are reserved for true systemic disruptions or natural disasters, such as cyberattacks, floods, or other events beyond a facility’s control. Routine operational challenges, including staffing shortages, turnover, or vacancies, do not qualify as extraordinary circumstances and are not valid reasons to request an ECE.
2. ECE Requests May Only Be Submitted After a Deadline Has Been Missed
CMS continues to receive unnecessary ECE requests from facilities that anticipate missing a reporting deadline. An ECE cannot be submitted in anticipation of a missed deadline. Facilities must wait until the reporting deadline has passed before submitting an ECE request.
Once an extraordinary circumstance has occurred, the completed ECE request form and all supporting documentation must be submitted within 60 days of the event.
3. Use the Correct Reporting Period When Determining PER Eligibility
Facilities should carefully verify that they are reviewing the correct reporting period and corresponding procedure codes when determining eligibility for a Participation Exemption Request (PER). Looking at the wrong timeframe or data set can result in an incorrect eligibility determination.
For example, if an ASC is determining whether it qualifies for a PER for the CY 2027 reporting period/CY 2029 payment determination, it should review survey eligible patients treated between January 1 and December 31, 2026. Looking at a different date range could lead to an incorrect eligibility determination.
4. A PER Must Be Renewed Every Year
Medicare certified hospitals and ASCs that treat fewer than 60 survey eligible patients during the applicable eligibility period may request a Participation Exemption Request (PER).
One important reminder from the webinar is that PER approvals are valid for only one reporting year. Facilities that continue to qualify must submit a new PER each year, as CMS reviews exemption requests annually. PER forms must be submitted by December 31 of the applicable data collection year.
5. Understanding How CMS Calculates the 240 Claim Threshold for ASCs
Another area of confusion addressed during the webinar was the automatic exemption available only to ambulatory surgery centers (ASCs). ASCs with fewer than 240 Medicare fee for service claims during the applicable period are automatically exempt from both the ASC Quality Reporting (ASCQR) Program and the OAS CAHPS Survey measure.
Unlike a Participation Exemption Request, this exemption does not require submission of an exemption form. CMS also clarified that the 240 claim threshold includes both primary and secondary Medicare fee for service claims. In addition, if multiple ASCs share the same CMS Certification Number (CCN), eligibility is determined separately for each ASC based on its National Provider Identifier (NPI), not at the CCN level.
What This Means for ASCs
Although ECEs and PERs represent only a small portion of the OAS CAHPS requirements, they continue to be a source of confusion for many facilities. Understanding when an exemption applies, how eligibility is determined, and when requests must be submitted can help organizations avoid unnecessary administrative work while maintaining compliance with CMS reporting requirements.
