Ambulatory Specialty Model (ASM)

Q: What is the Ambulatory Specialty Model?

A: The Ambulatory Specialty Model (ASM) is a mandatory, two-sided risk payment model from the CMS Innovation Center. ASM will initially cover 2 chronic conditions: heart failure and low back pain. It was designed to test whether holding specialists accountable for the quality and cost of care can lower Medicare spending while keeping care quality high.

CMS finalized ASM in the 2026 Physician Fee Schedule Final Rule. It takes effect Jan. 1, 2027 and will run for 5 performance years.

Payment adjustments for ASM will range from minus-9% to plus-9% for the first 2 performance years. The range will increase to minus-12% to plus-12% by the final performance year.

Q: Who’s required to participate in the Ambulatory Specialty Model?

A: Providers who meet all of the conditions below are required to participate in ASM:

1. Your specialty is cardiology (heart failure cohort) or anesthesiology, interventional pain management, neurosurgery, orthopedic surgery, pain management, or physical medicine and rehabilitation (low back pain cohort)
2. You’ve historically been attributed to 20-plus episodes per year based on your specialty’s episode-based cost measure
3. You practice in one of CMS’ selected geographic areas

Q: When does the Ambulatory Specialty Model begin?

A: Performance measurement runs for 5 years: Jan. 1, 2027 through Dec. 31, 2031. Payment adjustments for a performance year occur 2 years after the performance year. 2027 performance affects payments starting in the 2029 payment year, and the model’s payment years run through 2033.

Q: What are the requirements of the Ambulatory Specialty Model?

A: Each performance year, CMS will evaluate providers across 4 categories:

1. Quality: a focused set of clinical measures tied to each chronic condition and specialty
2. Cost: episode-based cost measures specific to a chronic condition, aimed at reducing unnecessary and avoidable care
3. Improvement Activities: efforts to improve screening for health-related social needs and strengthen care coordination between ASM specialists and primary care providers
4. Promoting Interoperability: measures and activities that promote using certified electronic health record technology (CEHRT) for data sharing and electronic communication

ASM features fixed measure sets. Providers are scored against peers managing the same condition, not against a national benchmark. They’ll need to submit data and attestations by March 31 following the end of each performance year.

ASM also requires providers to build formal care coordination with primary care.

Q: How do I know whether I’m required to participate in ASM?

A: CMS has published a preliminary list of clinicians required to participate in ASM for the 2027 performance year.

Participation is determined at the individual clinician level using the clinician’s TIN/NPI combination. To be included, a clinician must be in an eligible specialty, practice in one of CMS’ selected geographic areas, and have at least 20 attributed episodes under the applicable heart failure or low back pain episode-based cost measure.

For 2027 participation, CMS uses 2025 data to determine eligibility. CMS reassesses eligibility annually.

Healthmonix can check your TIN and NPI roster against CMS data and help identify which clinicians are affected.

Q: How does CMS attribute episodes to an ASM clinician?

A: CMS uses its episode-based cost measure methodology to attribute heart failure or low back pain episodes to individual clinicians.

Attribution is based on condition-specific triggering and confirming Medicare claims and the volume of services provided by an individual clinician. A clinician must have at least 20 attributed episodes during the eligibility year to meet ASM’s episode-volume threshold.

This makes attribution important to understand before the model begins. A clinician’s ASM performance can reflect the cost and utilization associated with an attributed episode, not simply the services billed directly by that clinician.

Q: How much money is at risk under ASM?

A: ASM is a two-sided risk model, meaning performance can result in either an increase or a decrease in future Medicare payments.

CMS will calculate a final ASM score based on performance across quality, cost, improvement activities and Promoting Interoperability. CMS will then compare clinicians with peers in the same ASM cohort and convert the score into a payment adjustment.

The adjustment ranges from -9% to +9% in the first two payment years and increases over the course of the model, reaching -12% to +12% by the final payment year.

The adjustment applies to Medicare Part B covered professional services, not just the services associated with ASM patients. Performance in 2027 determines the payment adjustment applied in 2029.

Q: What quality measures will I be required to report?

A: ASM uses a fixed set of quality measures for each clinical cohort.

For the heart failure cohort, CMS currently identifies:

• Q492: Risk-Standardized Acute Unplanned Cardiovascular-Related Admission Rates for Patients with Heart Failure — calculated by CMS from claims
• Q008: Heart Failure: Beta-Blocker Therapy for LVSD
• Q005: Heart Failure: ACE Inhibitor or ARB or ARNI Therapy for LVSD
• Q236: Controlling High Blood Pressure
• Q377: Functional Status Assessments for Heart Failure

For the low back pain cohort, CMS currently identifies:

• Q238: Use of High-Risk Medications in Older Adults
• Q134: Screening for Depression and Follow-Up Plan
• Q128: BMI Screening and Follow-Up Plan
• Q220: Functional Status Change for Patients with Low Back Impairments
• An administrative claims-based excess utilization measure

CMS has proposed changes to ASM for 2027, so practices should confirm the final 2027 measure set once the 2027 Physician Fee Schedule Final Rule is released.

Q: I’ve been successful in MIPS. Does that mean I’m ready for ASM?

A: Not necessarily.

ASM borrows elements of the MIPS Value Pathways framework, but it is a different payment model with different scoring and payment methodologies. ASM introduces a fixed measure set, condition-specific episode cost accountability, required care coordination, Promoting Interoperability requirements and two-sided financial risk.

Clinicians may also be required to collect measures they have never previously reported.

That makes early readiness assessment important. Practices should determine whether the required data are available today, whether workflows need to change, and how their historical cost and quality performance could translate into ASM financial exposure.

Q: Can I choose different quality measures under ASM?

A: No. Unlike traditional MIPS, ASM does not allow clinicians to select a different set of quality measures based on which measures are most advantageous or familiar to their practice.

CMS establishes a focused measure set for each ASM cohort. Participants must report the applicable cohort-specific measures, while CMS calculates administrative claims-based measures directly.

This means practices should identify data or workflow gaps before the 2027 performance year begins.

Q: What data will I need for ASM?

A: ASM draws on several types of data.

Practices will need clinical data to report the required quality measures and information needed to satisfy Promoting Interoperability and improvement activity requirements. CMS will calculate the cost category and certain quality measures using Medicare administrative claims.

ASM participants must also report a CEHRT ID, Promoting Interoperability measures and required attestations. The Promoting Interoperability performance period is 180 days, while required improvement activities have a 90-day performance period.

Most ASM participants will report quality at the individual TIN/NPI level. CMS permits participants in small practices of 15 or fewer NPIs to report quality at the group level.

Q: What does “two-sided risk” mean?

A: It means there is both upside and downside financial risk.

Clinicians who perform well relative to their ASM peers can receive a positive Medicare payment adjustment. Clinicians who perform poorly can receive a negative adjustment.

The adjustment is based on the clinician’s overall ASM performance across quality, cost, improvement activities and Promoting Interoperability — making ASM more than a quality reporting program.

Q: Can I opt out of ASM?

A: Generally, no.

ASM is a mandatory CMS Innovation Center model. Clinicians who meet CMS’ eligibility criteria are required to participate for each performance year in which they remain eligible, subject to limited exceptions established by CMS.

CMS reassesses eligibility annually. If a clinician no longer meets ASM eligibility requirements for a particular year, CMS will notify the clinician. The clinician may then be subject to regular MIPS requirements if otherwise eligible.

Q: Does ASM replace MIPS?

A: For most clinicians required to participate in ASM, yes.

ASM participants are generally exempt from MIPS requirements for the performance years in which they are required to participate in ASM. Instead, they report under ASM and receive an ASM payment adjustment.

However, ASM is not simply another MIPS reporting option. It has its own scoring methodology, payment methodology, required measures and activities.

Clinicians who are MIPS eligible in 2026 should still complete their 2026 MIPS reporting. ASM does not begin until Jan. 1, 2027.

Q: How is ASM different from MIPS or an MVP?

A: ASM uses parts of the MIPS Value Pathways framework, but it goes further.

ASM is mandatory for clinicians selected by CMS, uses a focused and fixed set of measures, holds specialists accountable for condition-specific episode costs, requires coordination with primary care, and places clinicians in two-sided financial risk.

Performance is also compared with other clinicians managing the same ASM condition.

The result is a shift from primarily reporting performance to being financially accountable for both the quality and cost of managing a defined patient population.

Q: What should practices be doing now to prepare for ASM?

A: Don’t wait until the 2027 performance year begins.

Practices should:

1. Determine who’s in ASM. Identify affected clinicians by TIN/NPI and confirm their ASM cohort.
2. Understand attribution. Determine which patients and episodes are likely to be attributed to each clinician and where cost and utilization risk may exist.
3. Assess quality readiness. Determine whether you currently capture the data required for every ASM quality measure and identify measures that require new workflows.
4. Evaluate interoperability readiness. Confirm CEHRT capabilities, data exchange processes and your ability to satisfy ASM’s Promoting Interoperability requirements.
5. Build primary care coordination. Establish the workflows, responsibilities and data-sharing processes needed to coordinate care with primary care providers.
6. Model financial exposure. Use historical clinical and claims data to understand where your clinicians may perform relative to their peers and where potential positive or negative payment adjustments could occur.

Q: How does Healthmonix help practices participating in the Ambulatory Specialty Model?

A: Healthmonix is a CMS-approved Qualified Registry and Qualified Clinical Data Registry. We help you:

• Determine your eligibility and readiness, including scoring feasibility, interoperability compliance, and data and attribution risk
• Build care coordination workflows and strengthen your primary care partnerships, with hands-on consulting
• Predict your ASM performance using your own clinical and claims data, so you can spot financial exposure before CMS scores are final

Send us your Taxpayer Identification Number (TIN) and National Provider Identifier (NPI) roster, and we’ll tell you within 2 business days which of your clinicians fall into an ASM cohort. It’s free, with no obligation.