GoHealthcare MSK Specialty Procedure Library™ | Healthcare Operations and Payer Intelligence Series
Developed by GoHealthcare Practice Solutions
CMS Ambulatory Specialty Model (ASM)
Low Back Pain Cohort: Operational, Documentation, and Revenue Readiness Guide for Musculoskeletal Specialty Practices
The Ambulatory Specialty Model is the first mandatory, individual clinician-level accountability model in Original Medicare to place musculoskeletal care at its center. Beginning January 1, 2027, selected anesthesiology, pain management, interventional pain management, neurosurgery, orthopedic surgery, and physical medicine and rehabilitation physicians will have their entire Medicare Part B professional revenue adjusted based on how they manage low back pain episodes. This guide translates the model into documentation, workflow, prior authorization, and revenue cycle terms.
00
CMS Ambulatory Specialty Model
How to Use This Guide
This guide is organized in four movements. Sections 1 through 8 establish what the Ambulatory Specialty Model is, who it captures, and how episodes are constructed and attributed. Sections 8 through 14 explain how performance is scored and converted into money. Sections 15 through 23 address the operational build: documentation, quality measure capture, cost levers, collaborative care arrangements, data infrastructure, and the interaction between the model and the prior authorization environment your practice already navigates. Sections 24 through 40 provide GoHealthcare's operational perspective, a case study, an implementation roadmap, frequently asked questions, and reference material.
Two conventions are used throughout. Where a design element is finalized in regulation, it is stated plainly. Where sources conflict, or where an element remains in proposed status, it is flagged in a callout box and identified as contested or unsettled. GoHealthcare does not present open questions as settled answers.
Back to guide navigation01
CMS Ambulatory Specialty Model
Executive Summary
The Ambulatory Specialty Model changes what Medicare pays musculoskeletal specialists for. It does not change coverage, coding, or prior authorization rules. It layers a five-year, two-sided performance adjustment on top of them, and it applies that adjustment to every Part B professional service the participating physician furnishes, not only to the low back pain services that generated the score.
The Centers for Medicare & Medicaid Services issued the final rule establishing the Ambulatory Specialty Model on October 31, 2025, as part of the calendar year 2026 Medicare Physician Fee Schedule final rule, published in the Federal Register on November 5, 2025. The model is authorized under Section 1115A of the Social Security Act and administered by the CMS Innovation Center. It has five performance years running from January 1, 2027 through December 31, 2031, with corresponding payment years from 2029 through 2033.
Two clinical conditions are in scope. Heart failure is assigned to general cardiology. Low back pain is assigned to six specialties that constitute the operational core of musculoskeletal specialty practice: anesthesiology, pain management, interventional pain management, neurosurgery, orthopedic surgery, and physical medicine and rehabilitation. For an MSK-focused organization, ASM is not a model to monitor from a distance. It is a model that scores the specific procedures the practice performs every day.
| # | Fact | Operational consequence |
|---|---|---|
| 1 | Participation is mandatory with no opt-out and no hardship exemption pathway. | Readiness planning is not a strategic option. It is a compliance and revenue obligation for any selected physician. |
| 2 | Participants are identified individually by Taxpayer Identification Number and National Provider Identifier. | A group cannot shelter an individual physician. Scores, and therefore adjustments, attach to the TIN and NPI combination. |
| 3 | Specialty is assigned by the plurality of the physician's Medicare Part B claims. | Billing pattern determines cohort assignment. Multi-specialty and subspecialty physicians should confirm the specialty CMS has assigned rather than the specialty they self-identify with. |
| 4 | The volume trigger is at least twenty attributed low back pain episodes per year under the episode-based cost measure. | Moderate-volume spine and interventional pain physicians are captured. This is not a high-volume-only model. |
| 5 | An episode counts toward a physician only if that physician billed at least thirty percent of the qualifying services in the episode. | Episode ownership is partly a function of billing pattern and can be measured in advance from existing MIPS episode feedback. |
| 6 | Quality and cost each carry fifty percent of the final score. | Documentation and utilization carry equal financial weight. Neither can compensate fully for the other. |
| 7 | Payment adjustments run from negative nine percent to positive nine percent in the first two performance years and rise to negative twelve to positive twelve percent by the final year. | The downside exceeds the total margin of many MSK practices on Medicare professional revenue. |
| 8 | Adjustments apply to all Medicare Part B covered professional services furnished by the participant in the payment year. | A surgeon's entire Part B book is exposed to performance on low back pain episodes alone. |
| 9 | Performance is measured on a two-year lag. | Calendar year 2027 conduct determines calendar year 2029 rates. There is no opportunity to correct retroactively. |
| 10 | Participants who satisfy ASM eligibility and data submission requirements are exempt from the Merit-based Incentive Payment System for that year. | ASM replaces MIPS rather than stacking on it, which simplifies reporting but concentrates all quality risk in one program. |
What GoHealthcare recommends practices do first Confirm participant status for every physician in the group against the current CMS participant dataset, using TIN and NPI rather than name. Pull the most recent MIPS episode-based cost measure feedback for low back pain and identify which physicians already carry twenty or more attributed episodes. Determine whether functional status outcome data are captured today in a structured, reportable field, and if not, treat that as the highest priority build. Inventory current primary care referral relationships and identify which could support a formal collaborative care arrangement. Confirm that the practice uses certified electronic health record technology capable of meeting the interoperability objectives. Model the downside. Calculate nine percent of total Medicare Part B professional revenue for each identified participant and present that figure to practice leadership.
Back to guide navigation02
CMS Ambulatory Specialty Model
Model at a Glance
The following table is the executive summary of the model design. Each element is developed in the sections that follow.
| Model name | Ambulatory Specialty Model (ASM) |
|---|---|
| Administering agency | Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services |
| Statutory authority | Section 1115A of the Social Security Act |
| Establishing regulation | CY 2026 Medicare Physician Fee Schedule final rule, issued October 31, 2025 and published in the Federal Register November 5, 2025 |
| Model type | Mandatory, two-sided risk alternative payment model |
| Conditions in scope | Heart failure; low back pain |
| MSK cohort specialties | Anesthesiology; pain management; interventional pain management; neurosurgery; orthopedic surgery; physical medicine and rehabilitation |
| Participant unit | Individual physician, identified by TIN and NPI |
| Performance years | Five years: 2027, 2028, 2029, 2030, 2031 |
| Payment years | 2029 through 2033, on a two-year lag |
| Volume threshold | At least twenty attributed low back pain episodes per year under the episode-based cost measure methodology |
| Geographic scope | Selected core-based statistical areas and metropolitan divisions, approximately one-quarter of all such areas nationally |
| Beneficiary population | Original Medicare fee-for-service |
| Performance categories | Quality; cost; improvement activities; promoting interoperability |
| Score range | Zero to one hundred |
| Payment adjustment range | Negative nine to positive nine percent in performance years 2027 and 2028; rising to negative twelve to positive twelve percent in performance year 2031 |
| Adjustment base | All Medicare Part B covered professional services furnished by the participant during the payment year |
| MIPS relationship | Participants meeting ASM eligibility and data submission requirements are exempt from MIPS for that performance year |
| Advanced APM status | Not designated as an Advanced Alternative Payment Model under MACRA |
| Opt-out | None. No hardship exemption pathway was established. |
| Prior authorization impact | None directly. ASM does not alter coverage criteria, prior authorization requirements, or coding rules. |
| Primary CMS source | https://www.cms.gov/priorities/innovation/innovation-models/asm |
03
CMS Ambulatory Specialty Model
Why CMS Built This Model
CMS has stated that more than two-thirds of people with Original Medicare live with at least one chronic condition and that care for those beneficiaries accounts for most Original Medicare spending. Heart failure and low back pain were selected as the first two conditions because both carry high annual Medicare spending, both are managed primarily by specialists in the ambulatory setting, and both show substantial variation in utilization that is not explained by clinical severity. CMS has cited annual Medicare spending in the range of ten to thirteen billion dollars for heart failure and six to eight billion dollars for low back pain.
The stated problem is fragmentation. Patients with these conditions commonly see multiple clinicians whose care is not coordinated, which CMS associates with treatment delays, unnecessary procedures, avoidable hospitalizations, and higher spending without corresponding improvement in outcomes. The
stated solution is to reward specialists for upstream management and for active coordination with primary care.
The strategic context ASM should be read as part of a deliberate sequence rather than as an isolated demonstration. The Innovation Center's earlier work concentrated accountability in primary care and in health systems: the Medicare Shared Savings Program, ACO REACH, Primary Care First. More recent mandatory models have moved accountability toward facilities and procedures, including the Comprehensive Care for Joint Replacement model and the Transforming Episode Accountability Model. ASM extends the same logic to individual specialist physicians in the ambulatory setting.
The American College of Surgeons has made the forward-looking point explicitly: because the majority of surgical care is now delivered in the outpatient setting, models targeting that setting are likely to expand. Practices should assume that the low back pain cohort is a template rather than an endpoint.
CMS stated goals • Increase active collaboration between select specialists and primary care providers. • Improve chronic disease management and prevent development of additional disease through better risk assessment. • Reduce avoidable hospitalizations and unnecessary procedures. • Offer greater transparency in participant performance. • Measure outcomes that center on patient priorities. • Align performance measures with factors specialists are better able to control.
Back to guide navigation04
CMS Ambulatory Specialty Model
Regulatory Timeline and Current Status
| Date | Event | Status |
|---|---|---|
| July 14, 2025 | ASM proposed in the CY 2026 Medicare Physician Fee Schedule proposed rule. | Complete |
| September 12, 2025 | Comment period on the CY 2026 proposed rule closed. Specialty societies including the American College of Surgeons, the American Society of Anesthesiologists, and AMGA submitted objections to the model design. | Complete |
| October 31, 2025 | CMS issued the CY 2026 Physician Fee Schedule final rule establishing ASM. | Complete |
| November 5, 2025 | Final rule published in the Federal Register. | Complete |
| January 2026 | CMS released the selected mandatory geographic areas. | Complete |
| February 2026 | CMS published the preliminary participant list, based on calendar year 2024 claims data. | Complete |
| April 8, 2026 | CMS held ASM participant office hours. | Complete |
| July 14, 2026 | CMS released the CY 2027 Physician Fee Schedule proposed rule containing proposed ASM refinements. Published in the Federal Register July 16, 2026. | Complete |
| July 2026 | CMS indicated a final participant list, based on calendar year 2025 claims data, would be published. | Verify current status |
| September 14, 2026 | Comment period on the CY 2027 proposed rule closes at 11:59 PM. | Open |
| Approximately November 1, 2026 | CY 2027 Physician Fee Schedule final rule expected. | Pending |
| January 1, 2027 | ASM performance year one begins. | Pending |
| Calendar year 2029 | First payment adjustments applied, based on performance year 2027. | Pending |
| December 31, 2031 | Final performance year concludes. | Pending |
| December 31, 2033 | Final payment year concludes. | Pending |
Preliminary participant scale CMS projected in the final rule that approximately 8,600 physicians would be required to participate, collectively managing roughly 600,000 heart failure and low back pain episodes annually for approximately 550,000 beneficiaries, representing approximately 2.8 billion dollars in annual episode spending.
The preliminary list published in February 2026 identified approximately 6,637 clinicians, of whom approximately 4,027 were assigned to the low back pain cohort and approximately 2,610 to the heart failure cohort. The low back pain cohort is therefore the larger of the two. Reported distribution is highly concentrated: the top ten states accounted for approximately 4,300 of the more than 6,600 preliminary participants, while the bottom ten states accounted for fewer than one hundred, with at least two states showing a single participant each.
Back to guide navigation05
CMS Ambulatory Specialty Model
Geographic Selection Methodology
Participation is geographically determined before it is individually determined. A physician who meets every specialty and volume criterion is not in the model unless the physician practices in a selected area. Understanding the selection methodology matters because it explains why certain markets were captured and because it signals how CMS is likely to expand the model.
CMS stratified core-based statistical areas and metropolitan divisions into six cohorts using three variables: average total Medicare Parts A and B episode spending, the volume of eligible episodes, and whether the area is a metropolitan division. Within each cohort, a share of areas was selected for mandatory participation.
| Cohort | Average Parts A and B episode spending | Volume of eligible episodes | Area type | Areas in cohort |
|---|---|---|---|---|
| 1 | Below median | Below median | CBSA | 160 |
| 2 | Below median | Above median | CBSA | 120 |
| 3 | Above median | Below median | CBSA | 124 |
| 4 | Above median | Above median | CBSA | 136 |
| 5 | Not applicable | At or above the 95th percentile | CBSA | 29 |
| 6 | Not applicable | Not applicable | Metropolitan division | 31 |
Stratification framework as described in the CY 2026 proposed rule. Figures published by Milliman citing 90 FR 32570.
Two descriptions of the selection share circulate, and they are reconcilable. CMS has publicly described the model as covering roughly one-quarter of core-based statistical areas and metropolitan divisions. Analysis of the proposed rule described approximately forty percent of the areas within each stratified cohort being selected. Because the six cohorts together contain approximately 600 areas, forty percent of that pool is approximately 235 to 240 areas, which is close to one-quarter of the roughly 900 core-based statistical areas nationally. Independent analysis of the published geographic file reported 235 selected metropolitan areas.
What geography does not determine • Geography determines eligibility for selection. It does not determine the peer comparison group. Participants are benchmarked against all participants nationally within their condition cohort, not against participants in their own market. • Geography is assessed at the point of practice location. Physicians practicing across a market boundary should confirm which location CMS used. • Geography does not shield a physician from the referral consequences of the model. A non-participating spine surgeon who receives referrals from a participating interventional pain physician will feel the referral pattern change even though the surgeon carries no direct adjustment.
Back to guide navigation06
CMS Ambulatory Specialty Model
Participant Eligibility Criteria
A physician located in a selected geographic area is an ASM participant only if all of the following criteria are met. The criteria are cumulative.
| Criterion | Requirement | What determines it |
|---|---|---|
| Billing basis | The physician submits claims under the Medicare Physician Fee Schedule. | Claims submission. Physicians who bill exclusively under other payment systems are outside the model. |
| Identification | The physician is identified by a combination of Taxpayer Identification Number and National Provider Identifier. | TIN and NPI pairing. A physician practicing under two TINs may be evaluated separately for each. |
| Specialty | The physician bills the plurality of Medicare Part B claims under an included specialty type. | Physician-reported specialty designation as assigned by the Medicare Administrative Contractor and reflected in claims. This is a claims determination, not a board certification determination. |
| Volume | The physician has at least twenty attributed low back pain episodes in a twelve-month period under the MIPS episode-based cost measure methodology. | Historical claims analysis performed by CMS. |
| Geography | The physician practices in a selected core-based statistical area or metropolitan division. | CMS geographic selection, published in the mandatory geographic areas file. |
Included specialties, low back pain cohort • Anesthesiology • Pain management • Interventional pain management • Neurosurgery • Orthopedic surgery • Physical medicine and rehabilitation General cardiology is the sole specialty in the heart failure cohort. Advanced practice professionals are not individually targeted under the model, even where they support care within a participating practice. This does not mean their documentation is irrelevant. Services furnished under a participating physician's arrangements will still appear in the episode, and functional status and screening documentation is frequently captured by advanced practice providers and nursing staff.
Duration of participation and the twenty-episode floor Once a physician is determined eligible, that physician remains an ASM participant for the duration of the model, even if the physician subsequently ceases to satisfy the eligibility criteria. This is a durable designation, not an annual re-qualification.
The twenty-episode threshold operates differently across the two purposes it serves. It is used at selection to identify who enters the model. It is also used within a performance year to determine whether a payment adjustment applies. Published analysis indicates that a participant who does not reach twenty attributed episodes in a given performance year remains an ASM participant and continues to be tracked for evaluation purposes but does not receive a payment adjustment for that year.
Back to guide navigation07
CMS Ambulatory Specialty Model
Episode Construction and Attribution
The low back pain episode is the unit of measurement in this model. Everything in the cost category and much of the quality category flows from how episodes open, how long they remain open, what falls inside them, and who owns them. Practices that understand episode mechanics can manage ASM. Practices that do not will experience the results as arbitrary.
How an episode opens The low back pain episode-based cost measure opens an episode when a trigger event is identified. The trigger requires a qualifying service accompanied by an ICD-10-CM diagnosis code indicating low back pain. Identification of the trigger opens a 120-day attribution window during which the patient's chronic condition care is monitored.
How an episode extends The attribution window continues for 120 days unless a service demonstrating a continuing care relationship is billed. Such a service is termed a reaffirming claim. When a reaffirming claim is billed by the same clinician group during an open attribution window, the window extends. This is why the low back pain episode has a variable length reported in the range of 120 to 484 days depending on continuity
of care with the specialist, in contrast to the heart failure episode which runs 365 to 729 days.
How an episode is attributed Attribution operates at two levels. At the clinician group level, episodes are assigned to the group maintaining the care relationship. At the TIN and NPI level, an episode is attributed to any clinician within the attributed clinician group who billed at least thirty percent of the trigger or confirming codes on Part B physician and supplier claim lines during the episode.
Additional integrity checks apply. Published measure specifications indicate that a TIN and NPI meeting the thirty percent threshold must also have billed at least one trigger or confirming code within one year prior to the episode, which prevents attribution to a clinician with no prior relationship to the patient.
| Clinician | Qualifying services billed in episode | Share | Attributed |
|---|---|---|---|
| Clinician A | 5 of 10 | 50 percent | Yes |
| Clinician B | 2 of 10 | 20 percent | No |
| Clinician C | 3 of 10 | 30 percent | Yes |
Illustrative application of the attribution threshold described in the CMS low back pain episode-based cost measure information form. More than one clinician can be attributed the same episode.
Services included in the low back pain episode Published analysis of the measure specifications identifies the following service categories as falling inside the low back pain episode window and therefore inside the cost measure.
| Category | Representative content |
|---|---|
| Spinal surgeries and procedures | Decompression, fusion, revision, and related operative services |
| Spinal injections and neurostimulators | Epidural steroid injections, facet interventions, radiofrequency ablation, spinal cord stimulation and related neuromodulation |
| Hospitalizations | Inpatient admissions occurring within the episode window |
| Imaging, diagnostics, and laboratory | Advanced imaging, plain radiography, diagnostic testing, and laboratory services |
| Outpatient visits | Office and outpatient evaluation and management encounters |
| Post-acute care services | Skilled nursing, home health, and inpatient rehabilitation following an episode-related admission |
| Therapy services and manipulation | Physical therapy, occupational therapy, and manipulative treatment |
| Medications | Pharmacy spending associated with the episode |
| Behavioral health and ancillary services | Behavioral health services and related ancillary care |
| Durable medical equipment | Braces, orthoses, stimulators, and related equipment |
| Patient transport | Ambulance and related transport |
| Telehealth | Telehealth services furnished within the episode |
08
CMS Ambulatory Specialty Model
Performance Category: Quality
Quality carries fifty percent of the final score. The quality architecture is drawn from the MIPS Value Pathways framework, but ASM narrows it in a way that matters: rather than allowing clinicians to select measures that fit their practice, ASM assigns a fixed measure set to each condition cohort and benchmarks participants only against peers treating the same condition.
Measurement strategy CMS has described the quality measurement strategy as focusing on three domains: excess utilization, evidence-based care and outcomes, and patient-reported outcomes and experience. Any addition or removal of a quality measure for an ASM cohort would apply prospectively only and would occur through notice and comment rulemaking.
Low back pain cohort measure set The measure set for the low back pain cohort, as described in published analysis of the rulemaking, consists of five measures.
| Measure | Type | What the practice must do | Difficulty |
|---|---|---|---|
| Lumbar Spine Imaging for Low Back Pain | Utilization / appropriateness | Avoid advanced lumbar imaging in the defined window following a new low back pain presentation absent qualifying clinical indications. | Moderate. Claims-based; no reporting burden but strong workflow implications. |
| Use of High-Risk Medications in Older Adults (MIPS Q238) | Medication safety | Avoid prescribing medications identified as high risk in patients 65 and older, or document the qualifying exception. | Moderate. Requires medication reconciliation discipline. |
| Preventive Care and Screening: Screening for Depression and Follow-Up Plan (MIPS Q134) | Preventive screening | Screen with a standardized tool and document a follow-up plan when the screen is positive. | Low to moderate. Standard tools exist; the follow-up plan is the usual failure point. |
| Preventive Care and Screening: Body Mass Index Screening and Follow-Up Plan (MIPS Q128) | Preventive screening | Document body mass index and a follow-up plan when outside parameters. | Low. Largely a structured-field capture problem. |
| Functional Status Change for Patients with Low Back Impairments (MIPS Q220) | Patient-reported outcome | Capture a validated functional status instrument at baseline and at follow-up and report the risk-adjusted change. | High. This is the measure that will separate participants. |
Quality scoring mechanics Each participant receives between one and ten achievement points for each measure, based on how the participant compares to measure-specific benchmarks. The benchmarks are set from the performance of other ASM participants on that measure in that year, and points are assigned by decile of performance. A participant in the top decile receives the full ten points for that measure.
Back to guide navigation09
CMS Ambulatory Specialty Model
Performance Category: Cost
Cost carries the other fifty percent of the final score. It is measured using the low back pain episode-based cost measure, the same measure used for participant selection and attribution. Spending is assessed per episode and compared to the distribution of per-episode costs across all ASM participants in the low back pain cohort for that year.
Cost scoring mechanics The cost measure score runs from zero to ten. A score of six corresponds to per-episode cost consistent with the median per-episode cost across ASM participants in that year. Costs above or below the median are assigned scores by linear interpolation within benchmark ranges defined in standard deviations from the median.
| Benchmark range | Points | Bottom of range |
|---|---|---|
| Range 1 | 1.0 to 1.9 | Median plus 2.5 standard deviations |
| Range 2 | 2.0 to 2.9 | Median plus 2 standard deviations |
| Range 3 | 3.0 to 3.9 | Median plus 1.5 standard deviations |
| Range 4 | 4.0 to 4.9 | Median plus 1 standard deviation |
| Range 5 | 5.0 to 5.9 | Median plus 0.5 standard deviation |
| Range 6 | 6.0 to 6.9 | Median |
| Range 7 | 7.0 to 7.9 | Median minus 0.5 standard deviation |
| Range 8 | 8.0 to 8.9 | Median minus 1 standard deviation |
| Range 9 | 9.0 to 9.9 | Median minus 1.25 standard deviations |
| Range 10 | 10 | Median minus 1.5 standard deviations |
Cost benchmark structure as published in analysis citing 90 FR 32588. Higher spending relative to peers yields fewer points.
Risk adjustment and what it does not cover The episode-based cost measure incorporates risk adjustment, and the final score incorporates a complex patient adjustment described in Section 11. Neither fully addresses the structural cost drivers that distinguish MSK subspecialties from one another. A neurosurgical practice whose referral pattern concentrates surgical candidates will carry higher per-episode costs than an interventional pain practice managing the same diagnosis conservatively, and both are scored against the same cohort median.
Back to guide navigation10
CMS Ambulatory Specialty Model
Performance Categories: Improvement Activities and
Promoting Interoperability The third and fourth performance categories operate differently from quality and cost. They do not carry positive weight in the final score. Published analysis of the rulemaking describes them as downside-only scoring adjustments applied after quality and cost are computed.
Improvement activities The improvement activities category focuses on two obligations: connecting to primary care and ensuring completion of health-related social needs screening, and establishing communication and collaboration expectations with primary care through collaborative care arrangements. Participants may also be assessed on participation in preventive care screening and lifestyle intervention activities.
Published analysis describes the improvement activities scoring adjustment as ranging from zero to negative twenty percent, applied in defined increments.
Promoting interoperability The promoting interoperability category assesses meaningful use of certified electronic health record technology. Reported objectives mirror MIPS promoting interoperability requirements and include electronic prescribing, querying of prescription drug monitoring programs, providing patients access to their health information, and supporting health information exchange. Data exchange is reportedly satisfied through electronic referral loops, bidirectional health information exchange, or exchange enabled under the Trusted Exchange Framework and Common Agreement. Reporting occurs through attestation and may occur at the TIN level.
Published analysis describes the promoting interoperability scoring adjustment as ranging from zero to negative ten percent.
Practical build requirements A written collaborative care arrangement template, reviewed by counsel, ready for execution with primary care partners. A defined health-related social needs screening instrument, a workflow for administering it, and a structured field to record the result. Confirmation that the practice's electronic health record is certified technology meeting current criteria. Electronic prescribing enabled and in routine use. Prescription drug monitoring program query integrated into the controlled substance workflow, which is already standard practice in most interventional pain settings. Patient access to health information through a functioning portal. At least one qualifying data exchange pathway operational. An attestation owner named, with a calendar obligation and a documentation file.
Back to guide navigation11
CMS Ambulatory Specialty Model
Final Score Construction
Each participant receives a final score for each performance year on a scale from zero to one hundred. The score is assembled from the four performance categories and then modified by two adjustments intended to recognize participants operating under structural disadvantage.
| Component | Effect on final score | Basis |
|---|---|---|
| Quality | Fifty percent weight | Five condition-specific measures, one to ten achievement points each, benchmarked by decile against other ASM participants |
| Cost | Fifty percent weight | Low back pain episode-based cost measure, zero to ten points, benchmarked against the participant cohort median in standard deviation ranges |
| Improvement activities | Scoring adjustment of zero to negative twenty percent | Primary care connection, health-related social needs screening completion, collaborative care arrangements |
| Promoting interoperability | Scoring adjustment of zero to negative ten percent | Certified electronic health record technology objectives, reported by attestation |
| Complex patient adjustment | Positive adjustment of up to ten percent | Participants serving a high proportion of patients with elevated medical and social risk |
| Small practice adjustment | Positive adjustment of ten percent | Practices consisting of fifteen or fewer clinicians, counting advanced practice providers |
Complex patient adjustment The complex patient adjustment provides up to a ten percent positive adjustment for participants treating patients with higher medical and social risk. For MSK practices, this is the mechanism through which case mix reaches the score, and it is the reason that documentation of comorbidity and social risk has direct financial value under this model even when it does not change the level of service billed.
Back to guide navigation12
CMS Ambulatory Specialty Model
Payment Adjustment Mechanics
The final score does not translate directly into a percentage. CMS converts scores into payment adjustments through a redistribution mechanism that makes the model approximately budget neutral, which means that a participant's adjustment depends not only on the participant's own performance but on the performance of everyone else in the cohort.
| Performance year | Payment year | Risk level |
|---|---|---|
| 2027 | 2029 | 9 percent |
| 2028 | 2030 | 9 percent |
| 2029 | 2031 | 10 percent |
| 2030 | 2032 | 11 percent |
| 2031 | 2033 | 12 percent |
The incentive pool All participants in a cohort are included in an incentive pool representing the total funds available to determine payment adjustments. Published analysis describes the pool as calculated by multiplying all Medicare Part B payments made to ASM participants during the performance year by the applicable risk level and then by a redistribution percentage. The redistribution percentage was specified as eighty-five percent for 2027, with the remaining fifteen percent directed to the Medicare Trust Fund.
Score-to-adjustment conversion To distribute the pool, CMS transforms each participant's score using a logistic exchange function. CMS has not published the exact function but has indicated that the logistic form was selected because it produces adjustments for participants at the extremes of performance that are similar in magnitude to those for participants with moderately high or low performance, smoothing results at the tails.
The resulting adjustment percentage is then applied to the participant's total Medicare Part B payments in the payment year. A participant receiving a positive adjustment of three and a half percent for performance year 2027 would receive an additional three and a half percent of 2029 Part B payments.
Financial exposure worksheet The following framework is intended for practice leadership. It is deliberately simple, because the point is to make the magnitude visible rather than to produce an actuarial estimate.
| Step | Input | Source |
|---|---|---|
| 1 | Identify each physician in the group appearing on the CMS participant list. | CMS participant dataset, matched by TIN and NPI |
| 2 | For each, total Medicare Part B professional payments for the most recent complete year. | Practice management system, Medicare payments only |
| 3 | Multiply by nine percent. This is the year one downside and the year one upside. | Risk level for performance year 2027 |
| 4 | Multiply by twelve percent. This is the exposure by the final performance year. | Risk level for performance year 2031 |
| 5 | Sum across participating physicians. Compare against the group's annual operating margin. | Practice financial statements |
| 6 | Repeat, assuming the practice fails to report the functional status measure and scores zero on it. | Sensitivity check on the single largest capability gap |
13
CMS Ambulatory Specialty Model
Model Waivers and Flexibilities
Alongside the accountability provisions, CMS finalized several flexibilities intended to make it easier for participants to deliver care under the model. These are genuine operational assets and are frequently overlooked in summaries that focus on downside risk.
Beneficiary engagement incentives CMS will permit participating clinicians to offer in-kind patient engagement incentives valued at up to one thousand dollars per beneficiary. Reported permissible examples include support for participation in education or coaching programs, use of remote monitoring tools such as blood pressure monitors, vouchers for healthy food, and gym memberships. This is made possible through a waiver of certain fraud and abuse provisions, including specified Anti-Kickback Statute provisions, that would otherwise prohibit incentives that could be viewed as inducing beneficiaries to seek care from a particular provider. Published commentary describes this as the first time such an allowance has appeared in a specialty-focused Medicare model.
Telehealth flexibility The model includes a telehealth waiver. Telehealth services also appear as an included service category within the low back pain episode, which means telehealth utilization is captured in the cost measure. Practices should treat telehealth as an efficiency tool within the episode rather than as an additional service layer.
Safe harbor for collaborative care arrangements Published analysis reports that the model provides a safe harbor for collaborative care arrangements with primary care. Because these arrangements are simultaneously an improvement activities requirement and a relationship between referral-connected providers, the availability of a defined safe harbor is operationally significant. It permits practices to formalize arrangements they might otherwise structure loosely to avoid regulatory ambiguity.
Back to guide navigation14
CMS Ambulatory Specialty Model
Relationship to MIPS, MVPs, and Advanced APM Status
ASM is built on the MIPS Value Pathways framework but is not MIPS. The differences determine what reporting obligations a participating physician actually carries.
| Dimension | Traditional MIPS | Ambulatory Specialty Model |
|---|---|---|
| Measure selection | Clinician selects measures from a broad inventory. | Fixed measure set assigned by condition cohort. No selection. |
| Comparison group | Performance compared against the full pool of MIPS participating clinicians regardless of specialty. | Performance compared only against participants treating the same condition. |
| Category weighting | Four categories with weights that shift by year and clinician type. | Quality and cost at fifty percent each; improvement activities and promoting interoperability as scoring adjustments. |
| Participation | Determined by eligibility thresholds; various exclusions available. | Mandatory for selected clinicians. No opt-out, no hardship exemption pathway. |
| Maximum adjustment | Plus or minus nine percent. | Plus or minus nine percent rising to plus or minus twelve percent by the final performance year. |
| Advanced APM status | Not applicable. | ASM is not designated as an Advanced Alternative Payment Model under MACRA. |
MIPS exemption Participants who satisfy ASM eligibility and data submission requirements for a performance year are exempt from MIPS reporting for that year. This removes a reporting burden but concentrates risk: there is
no longer a separate program in which strong performance can offset ASM results.
Broader MIPS trajectory In the CY 2027 proposed rule CMS proposed sunsetting traditional MIPS reporting in 2029 and transitioning clinicians toward MIPS Value Pathways. Read together with ASM, the direction is consistent: condition-specific and specialty-specific measure sets replacing clinician-selected measure portfolios. Practices building ASM capability are building capability that will be required regardless of ASM's own future.
Back to guide navigation15
CMS Ambulatory Specialty Model
What ASM Does Not Change
Because ASM is a payment model rather than a coverage policy, several things that practices might expect to change do not. Stating these explicitly prevents a common category error.
| Domain | Status under ASM | Practical meaning |
|---|---|---|
| National and local coverage determinations | Unchanged. | An epidural steroid injection that does not meet the applicable local coverage determination is still non-covered. ASM adds no coverage and removes none. |
| Prior authorization requirements | Unchanged. | Medicare Advantage plan requirements, commercial payer requirements, and delegated vendor review criteria all continue to operate as before. |
| The WISeR Model | Separate and unchanged. | The prior authorization and pre-payment review demonstration for selected services operates on its own schedule, in its own geographies, under its own rules. |
| CPT, HCPCS, and ICD-10-CM coding rules | Unchanged. | Code selection, modifier application, and documentation-to-code alignment obligations are identical. |
| National Correct Coding Initiative edits | Unchanged. | Bundling, mutually exclusive edits, and medically unlikely edits continue to apply. These are updated quarterly and must be verified against the current quarter. |
| Medical necessity standards | Unchanged. | Documentation must still establish medical necessity for the service billed. |
| Fee schedule payment rates | Unchanged at the service level. | ASM adjusts total Part B payments retrospectively. It does not reprice individual services. |
| Site of service rules | Unchanged. | Ambulatory surgery center covered procedures lists, payment indicators, and facility rules operate independently. |
16
CMS Ambulatory Specialty Model
Interaction with the Prior Authorization Environment
For an MSK specialty management services organization, the most important analytical question about ASM is how it interacts with the utilization management architecture practices already navigate. The answer is that the two systems apply pressure to the same procedures from opposite directions and on different timelines.
| Dimension | Utilization management and prior authorization | Ambulatory Specialty Model |
|---|---|---|
| Timing | Prospective. Before the service. | Retrospective. Two years after the performance year. |
| Unit | The individual service or course of treatment. | The episode, aggregated across all services and all providers within the window. |
| Decision maker | Payer or delegated review vendor. | CMS, by formula, against a peer benchmark. |
| Consequence of failure | Service not authorized or not paid; appeal available. | Score reduction leading to a percentage adjustment on all Part B payments; no service-level appeal of the score. |
| What good performance looks like | Complete documentation satisfying published criteria. | Lower per-episode spending and better measured outcomes relative to peers. |
| Effect of a denial | Revenue lost on that service. | Spending avoided within the episode, which improves the cost score. |
Where the two systems reinforce each other The interaction is not purely adversarial. Several disciplines improve performance in both systems simultaneously, and these are where MSK practices should concentrate.
| Discipline | Prior authorization benefit | ASM benefit |
|---|---|---|
| Documented conservative therapy trial with dates, modalities, duration, and response | Satisfies the conservative therapy requirement common to Medicare local coverage determinations and to commercial and delegated vendor criteria. | Reduces premature advanced intervention within the episode, which lowers episode cost and supports imaging appropriateness. |
| Structured functional status measurement at baseline and follow-up | Strengthens medical necessity documentation and supports repeat procedure justification under criteria requiring documented functional benefit. | Is the direct data source for the functional status change quality measure, which is the highest-difficulty measure in the set. |
| Imaging discipline aligned to appropriateness criteria | Prevents denials for imaging not meeting coverage criteria and avoids repeat imaging requests during review. | Directly drives the lumbar spine imaging quality measure and reduces diagnostic spending within the episode. |
| Coordinated care planning with primary care | Produces a cleaner referral record and a more complete conservative care history at the time of submission. | Satisfies the collaborative care arrangement improvement activity and reduces duplicative workup. |
| Accurate comorbidity and social risk documentation | Supports medical necessity where comorbidity affects candidacy and risk. | Feeds risk adjustment and the complex patient adjustment. |
17
CMS Ambulatory Specialty Model
Documentation Requirements Driven by ASM
ASM does not create new documentation regulations. It creates new financial consequences for documentation that was previously optional or informal. The following requirements are organized by the performance category they serve.
Documentation supporting the quality category A validated functional status instrument administered at the initial evaluation, recorded in a structured, extractable field rather than in narrative text. The same instrument re-administered at a defined follow-up interval, with both scores linked to the same episode. A standardized depression screening instrument administered and scored, with a documented follow-up plan when the screen is positive. Body mass index recorded as a discrete value, with a documented follow-up plan when outside defined parameters. Complete medication reconciliation, with explicit documentation where a medication identified as high risk in older adults is continued for a documented clinical reason. Imaging orders with documented clinical indication, including the specific findings or red flag features supporting advanced imaging when ordered early in a presentation.
Documentation supporting the cost category A dated, itemized conservative therapy history covering modality, duration, adherence, and response.
Explicit documentation of the decision not to proceed to an intervention where that decision was made, which creates the record that lower spending reflected judgment rather than access failure. Documentation of coordination that avoided duplicate imaging or duplicate workup. A defined discharge or transition plan for patients whose active specialty management has concluded.
Documentation supporting the improvement activities and interoperability categories An executed collaborative care arrangement with each participating primary care partner, retained and retrievable. Health-related social needs screening administered and recorded in a structured field. A documented care transition plan for movement between settings. Records supporting each promoting interoperability objective attested to, retained for the applicable period.
Back to guide navigation18
CMS Ambulatory Specialty Model
Operationalizing the Functional Status Measure
This section is given disproportionate space because the functional status change measure is, by a wide margin, the largest capability gap facing the low back pain cohort. It is a patient-reported outcome measure in a set of specialties with essentially no reporting history on it.
Why this measure is different • It requires two data points per patient rather than one, separated in time, and both must attach to the same episode. • The data originate with the patient rather than with the clinician, which means capture depends on patient completion rates rather than on clinician behavior alone. • It is risk-adjusted, which means the raw score change is not the reported value and the reporting mechanism matters. • It has no established workflow in most interventional pain, neurosurgical, and orthopedic practices, unlike depression screening or body mass index which are near-universal in primary care and commonly present in specialty settings.
| Ste p | Action | Owner | Common failure |
|---|---|---|---|
| 1 | Select the instrument and confirm it satisfies the measure specification. | Clinical leadership with quality lead | Selecting a familiar instrument that is not among those accepted by the specification. |
| 2 | Determine the collection modality: portal, tablet at check-in, or staff-administered. | Practice administration | Choosing a single modality and losing the patients it does not reach. |
| 3 | Define the baseline trigger point and hard-code it into scheduling and rooming workflow. | Front office and clinical staff leadership | Leaving baseline capture to clinician discretion, which produces sporadic completion. |
| 4 | Define the follow-up interval consistent with the measure specification and build an automated task or outreach. | Practice administration with information technology | Relying on the next scheduled visit, which misses patients who improve and do not return. |
| 5 | Confirm the score writes to a structured field that the reporting pathway can extract. | Information technology and electronic health record vendor | Discovering after a year of collection that scores live in unstructured notes. |
| 6 | Establish the reporting pathway and confirm end to end with a test submission. | Quality lead | Assuming the electronic health record vendor supports the measure without confirming. |
| 7 | Monitor completion rate weekly for the first quarter and monthly thereafter. | Quality lead | Monitoring only the score and not the denominator, so low completion is discovered late. |
19
CMS Ambulatory Specialty Model
Managing Episode Cost
Cost performance is half the score. The following levers are organized from the least clinically intrusive to the most, and GoHealthcare recommends exhausting the earlier ones before considering the later ones.
Tier one: eliminate waste that no one defends • Duplicate imaging. Obtain and review outside imaging before repeating it. Establish a records retrieval workflow that operates before the visit rather than during it. • Redundant diagnostic testing ordered in parallel by multiple clinicians managing the same patient. • Avoidable emergency department utilization for pain exacerbation, addressed through defined after-hours access and escalation pathways. • Post-acute utilization that exceeds clinical need because no discharge plan was established before the procedure.
Tier two: sequence care to the evidence • Ensure documented conservative therapy precedes advanced intervention where criteria and evidence support it. This aligns with nearly every payer coverage policy already governing these services. • Apply diagnostic block discipline where the relevant coverage policy requires it, rather than proceeding to definitive intervention without the confirming step, which frequently produces both a denial and a repeated episode of care. • Avoid advanced imaging early in a new presentation absent red flags or qualifying indications, consistent with the lumbar spine imaging quality measure.
Tier three: address structural spending • Site of service. Where a procedure is clinically appropriate in an ambulatory surgery center rather than a hospital outpatient department, the facility cost differential is substantial and falls inside the episode. • Device selection where multiple cleared options exist with materially different cost profiles and comparable clinical indications. • Care team design, given that two clinicians each billing above the thirty percent attribution threshold both carry the full episode cost.
Back to guide navigation20
CMS Ambulatory Specialty Model
Collaborative Care Arrangements
The collaborative care arrangement is the improvement activity that will require the most external negotiation. CMS describes these arrangements as establishing clearly defined roles, responsibilities, and expectations for data sharing, co-management of patient care, and referral processes between the participating specialist and primary care providers. Both parties may contribute to health-related social needs screening, and both jointly prepare plans for patient transitions between care settings.
Minimum content of a workable arrangement Named parties, including the specific specialist participants covered and the primary care entity. Defined division of responsibility for chronic low back pain management, stating which party owns medication management, imaging ordering, therapy referral, and specialty escalation. A referral pathway with defined information to accompany a referral, including prior conservative therapy, prior imaging, and current functional status. A data sharing mechanism and cadence, specifying format, frequency, and the electronic exchange pathway used. Assignment of responsibility for health-related social needs screening, and a mechanism for sharing the result. A care transition protocol covering movement between the outpatient setting, procedural settings, and home. A defined process for closing the loop after specialty evaluation, including what is communicated back and within what interval. Term, renewal, and termination provisions. Regulatory review confirming the arrangement is structured within the applicable safe harbor.
Practical negotiation guidance Primary care practices have no obligation to enter these arrangements and generally receive no ASM benefit from doing so. Specialists should expect to make the case on grounds other than the specialist's own scoring requirement.
• Lead with what the primary care practice gains: faster specialty access, structured closed-loop communication, and reduced duplicate workup for shared patients. • Offer to carry the administrative burden, including drafting, data exchange configuration, and maintenance. • Start with the referral sources that already send the highest volume, where a formal arrangement documents an existing relationship rather than creating a new one. • Do not condition referral acceptance, scheduling priority, or any other benefit on execution of an arrangement. • Build the arrangement around information flow rather than around volume, which is both the correct clinical design and the safer regulatory posture.
Back to guide navigation21
CMS Ambulatory Specialty Model
Data, Analytics, and Reporting Infrastructure
CMS has indicated that participants will receive access to enhanced performance data relating to episode-based costs, utilization, and quality, intended to give deeper insight into patient care patterns and needs. Model data of this kind arrives on a defined cadence and in raw form. The value of the data depends entirely on whether the practice has the capability to use it.
| Capability | Question it answers | Consequence of not having it |
|---|---|---|
| Episode-level cost decomposition | Which service categories drive per-episode cost, and which physicians and which patient cohorts drive the outliers. | Cost improvement efforts are directed by intuition rather than by where the spending actually is. |
| Attribution tracking | Which episodes are attributed to which physician, and where two physicians in the group both cross the thirty percent threshold on the same episode. | Care team design decisions are made without visibility into their scoring effect. |
| Quality measure completion monitoring | What proportion of the eligible denominator has a captured baseline and follow-up functional status score. | Low capture rates are discovered at year end rather than in month two, when they are still correctable. |
| Peer benchmark positioning | Where the practice sits relative to the cohort median on cost and relative to decile boundaries on quality. | Effort is expended without knowing whether it moves the practice across a scoring boundary. |
| Financial modeling | What the projected adjustment is worth in dollars at the current trajectory. | Leadership cannot prioritize ASM against competing operational investments. |
Governance
• Name a single accountable owner for ASM performance. Distributed ownership across quality, revenue cycle, and clinical leadership reliably produces gaps at the seams. • Establish a monthly review cadence with a standing agenda covering capture rates, episode cost trend, attribution changes, and outstanding compliance items. • Report physician-level results to physicians. Aggregate reporting does not change individual behavior, and adjustments are individual. • Document the governance process itself. Under an AI governance and compliance framework, the record of how performance decisions were made is as important as the decisions.
Back to guide navigation22
CMS Ambulatory Specialty Model
CY 2027 Proposed Rule: Proposed ASM Refinements
CMS released the CY 2027 Medicare Physician Fee Schedule proposed rule on July 14, 2026, published in the Federal Register on July 16, 2026. It contains proposed refinements to ASM. Comments are due by 11:59 PM on September 14, 2026, and a final rule is expected in the fall of 2026, approximately two months before the model begins.
| Proposed change | What it would do | Who it affects |
|---|---|---|
| Participant exceptions for Taxpayer Identification Number changes | Create a defined exception pathway for participants whose TIN changes, addressing practice acquisitions, mergers, and employment changes. | Physicians changing employment or practices undergoing transactions between selection and the performance year. |
| Participant exceptions for specialty redesignation | Create a pathway for physicians who formally redesignate their Medicare primary specialty. Reported conditions in the analogous cardiology context include formal redesignation through an approved PECOS or paper CMS-855 enrollment application, written notice to CMS, and submission of board certification verification in the newly designated specialty within thirty days of the effective date. | Subspecialists captured by plurality-of-claims assignment into a cohort that does not reflect their practice. |
| Subspecialty-based exclusions | Exclude certain participants from a cohort based on subspecialty. | Subspecialists whose practice does not include the target condition. |
| Improvement activities flexibility for small practices | Add reporting flexibility in the improvement activities category for small practices. | Independent and small group MSK practices. |
| New low back pain imaging measure | Add an imaging measure to the low back pain quality measure set. | The entire low back pain cohort. Would change the measure set practices are building toward. |
| Voluntary patient-reported outcome data submission incentive | Create a voluntary incentive for submitting patient-reported outcome data. | Practices with functional status and patient-reported outcome capture already built. |
| Rural adjustment | Add an adjustment for rural participants. | Participants in areas designated as rural. |
| Clarified quality measure scoring | Clarify how quality measures are scored. | All participants. |
Proposed changes as reported by AMGA, the American Hospital Association, McDermott+, and the Heart Rhythm Society following the July 14, 2026 release. Read the Federal Register text before relying on any specific provision.
What the proposals signal • CMS is responsive to operational objections but not to structural ones. The proposed refinements address administrative pain points such as TIN changes and subspecialty misassignment. AMGA characterized them as technical fixes that leave the structural concerns raised since finalization untouched. • The proposed voluntary patient-reported outcome incentive suggests CMS recognizes the difficulty of the functional status measure and is attempting to encourage capture through a positive rather than punitive mechanism. Practices already building that capability are positioned to benefit. • The proposed rural adjustment and small practice improvement activities flexibility indicate CMS is addressing structural disadvantage at the margins rather than reweighting the model. • A proposed new imaging measure this close to launch is a reminder that the measure set is not fixed. Practices should build measurement infrastructure that is instrument-agnostic and can accommodate additions.
Back to guide navigation23
CMS Ambulatory Specialty Model
Ambulatory Surgery Center and Hospital Outpatient
Considerations ASM participants are physicians, not facilities. No ambulatory surgery center or hospital outpatient department is an ASM participant and no facility receives an ASM payment adjustment. Facilities are nonetheless affected, in two directions.
| Effect | Mechanism | Facility response |
|---|---|---|
| Facility spending enters the physician's episode | Spinal surgeries and procedures, spinal injections and neurostimulators, hospitalizations, and post-acute care are included service categories within the low back pain episode. The facility component of that spending counts. | Understand which of the facility's cases fall inside a participating physician's episode and be prepared for cost conversations. |
| Site of service migration | Where a procedure is appropriate in an ambulatory surgery center, the cost differential relative to a hospital outpatient department reduces episode spending. | Ambulatory surgery centers should expect volume interest from participating physicians. Hospital outpatient departments should expect pressure on cases that could migrate. |
| Device and implant cost scrutiny | Implant and device cost falls inside the episode where it is billed within the window. | Expect more physician engagement in device selection and contracting than has historically been typical. |
| Post-acute pathway design | Post-acute care services are an included category. Discharge destination materially affects episode cost. | Pre-procedure discharge planning becomes a shared interest rather than a facility administrative task. |
| Documentation dependency | Functional status and screening capture often occur in the facility encounter rather than the office encounter. | Facilities and physician practices need aligned capture workflows so that data collected in one setting reaches the other. |
24
CMS Ambulatory Specialty Model
Common Mistakes
The following errors are drawn from GoHealthcare's experience supporting MSK practices through prior authorization, utilization management, and value-based program transitions, applied to the ASM context.
| Mistake | Why it happens | Correction |
|---|---|---|
| Treating ASM as a quality reporting project | It arrives through the physician fee schedule and uses MIPS vocabulary, so it is routed to whoever handled MIPS. | Route it to whoever owns the Medicare revenue line. Half the score is cost, and the adjustment applies to all Part B revenue. |
| Checking participant status by physician name | The published lists are searchable by name and it is the fastest check. | Verify by TIN and NPI. Name matching produces both false positives and false negatives, and the TIN and NPI pairing is the actual unit of participation. |
| Relying on the February 2026 preliminary list | It was published first and received the most coverage. | The final list is built on a different claims year. Confirm against the current CMS dataset. |
| Assuming a subspecialist is excluded | Clinical identity feels determinative. | Cohort assignment follows plurality of Part B claims, not self-identification or board certification. Confirm the assignment. |
| Deferring functional status capture until 2027 | The performance year has not started, so the work feels premature. | Capture workflows take months to reach reliable completion rates. A workflow that begins January 1, 2027 will produce poor first-half data in a year that determines 2029 payment. |
| Capturing required data in narrative text | It is how clinicians document and it satisfies the clinical purpose. | Quality measure reporting requires structured fields. Confirm each element writes to a discrete, extractable location. |
| Over-investing in interoperability attestation | It is concrete, checkable, and feels like progress. | Under the downside-only reading, interoperability cannot raise a score. Satisfy it efficiently and redirect capacity to quality and cost. |
| Executing collaborative care arrangements without counsel | They look like administrative documents. | They are arrangements between referral-connected providers. Counsel review is not optional. |
| Modeling average performance as a zero adjustment | Budget neutrality is assumed. | A portion of the at-risk pool is directed to the Medicare Trust Fund rather than redistributed. Model accordingly. |
| Reducing indicated care to protect a cost score | The incentive is real and the pressure is real. | This is clinically indefensible and creates liability and regulatory exposure. Use waste elimination, evidence-consistent sequencing, and site of service instead, and document the governance position. |
| Ignoring the small practice adjustment before a structural decision | Practice structure decisions are made for other reasons. | A ten percent score adjustment for practices of fifteen or fewer clinicians is material. Know the threshold before restructuring. |
| Treating ASM and prior authorization as the same problem | Both involve documentation and both involve payers. | They operate prospectively versus retrospectively, at service versus episode level, and can produce opposite conclusions. Manage both. |
25
CMS Ambulatory Specialty Model
Pearls and Pitfalls
Pearls • The disciplines that produce prior authorization approvals are largely the same disciplines that produce ASM performance. A strong authorization operation is most of an ASM operation. • Structured functional status capture returns twice: once as the highest-difficulty ASM quality measure, and once as the strongest available evidence in repeat procedure authorization requests and appeals. • Existing MIPS episode-based cost measure feedback for low back pain uses the same underlying methodology as ASM cost scoring and is available today. • Benchmarks are set from participant performance, which means early capability builders benefit disproportionately in the first two performance years. • The small practice adjustment is available to practices of fifteen or fewer clinicians and exceeds the likely first-year gain on most individual measures. • Documented decisions not to intervene create the record that low spending reflected clinical judgment rather than access failure.
Pitfalls • Attribution is not divided. Two physicians in the same group can each carry the full cost of the same episode. • Episodes extend with continued care, so practices holding long-tenured chronic panels accumulate longer and more expensive episodes for structural reasons. • Comorbidity and social risk that are documented only in narrative do not reach risk adjustment or the complex patient adjustment. • Failure to report a required measure produces a score of zero on that measure, not an exclusion from it. • Participation is durable. Falling below the twenty-episode threshold does not remove a physician from the model. • The beneficiary incentive waiver is narrow. Exceeding its conditions converts a permitted incentive into potential Anti-Kickback Statute exposure. • The quality measure set is not fixed. A new imaging measure was proposed for the low back pain cohort in July 2026.
Back to guide navigation26
CMS Ambulatory Specialty Model
GoHealthcare Prior Authorization and Operations
Insight
This section reflects GoHealthcare Practice Solutions' operational perspective as a national musculoskeletal specialty management services organization. It addresses what practices should do differently, drawn from patterns observed across prior authorization, utilization management, and revenue cycle operations rather than from regulatory text.
The reframe that matters most
Most practices encountering ASM classify it as a quality program because it uses quality program vocabulary and arrives through the physician fee schedule. That classification determines who owns it, and the ownership determines the outcome. A quality lead will build measure capture and will do it competently. A quality lead will not typically model twelve percent of Medicare professional revenue against operating margin, will not typically redesign site of service pathways, and will not typically negotiate collaborative care arrangements with referral partners.
ASM is a revenue program with a quality measurement mechanism. It should be owned by whoever owns Medicare revenue performance, with the quality lead as a named contributor. This single organizational decision has more effect on outcomes than any measure-level tactic in this guide.
| Observable pattern today | What it predicts under ASM |
|---|---|
| High rate of denials citing insufficient conservative therapy documentation | Cost measure difficulty. The same documentation gap that fails a coverage criterion typically reflects a sequencing pattern that raises episode cost. |
| Repeat procedure authorizations denied for absence of documented functional benefit | Direct exposure on the functional status change measure. The practice is already being asked for this data by payers and cannot produce it. |
| Frequent peer-to-peer reviews on imaging requests | Exposure on the lumbar spine imaging measure and elevated diagnostic spending within the episode. |
| High volume of records requests for outside imaging during review | Duplicate imaging risk, which is the most defensible cost reduction available and usually the largest. |
| Authorization submissions assembled by abstracting narrative notes | Quality measure reporting difficulty. If a human must read the note to find the data, the reporting pathway cannot extract it either. |
| Fragmented referral relationships with no closed-loop communication | Improvement activities exposure and duplicative workup within the episode. |
Denial prevention practices that transfer directly • Front-loading records retrieval so that outside imaging and prior conservative therapy documentation are in hand before the initial consultation rather than assembled during a review. • Standardized medical necessity templates that require the specific elements payers request, which are largely the same elements the ASM quality measures require. • A named authorization owner per case with escalation authority, which reduces both denial rates and the duplicated workup that inflates episode cost. • Structured post-procedure follow-up at a defined interval, which simultaneously produces the follow-up functional status score and the documented outcome that supports the next authorization. • Internal quality assurance review of a sample of submissions each month, extended under ASM to include a sample of measure capture completeness.
Internal quality assurance recommendations for ASM Monthly review of functional status capture rate by physician and by location, reported against a stated target. Quarterly reconciliation of attributed episodes against the practice's own patient panel to identify attribution the practice did not expect. Quarterly review of episode cost decomposition by service category with a named owner for the largest category. Annual review of collaborative care arrangements for currency, including confirmation that named parties remain accurate. Documented review of any AI-assisted tool influencing patient stratification or documentation, under the practice's AI governance framework. A standing written statement, approved by clinical leadership, that cost performance does not override clinical judgment, distributed to all clinicians and retained.
Back to guide navigation27
CMS Ambulatory Specialty Model
GoHealthcare Leadership Perspective
The Ambulatory Specialty Model represents a change in what Medicare is purchasing from musculoskeletal specialists. Under fee-for-service, Medicare purchases services. Under ASM, Medicare continues to purchase services but retrospectively adjusts what it paid based on whether the aggregate pattern of services produced measured functional improvement at competitive cost. The unit of accountability moves from the procedure to the episode, and from the practice to the individual physician.
Three executive observations First: the accountability unit is the individual Most value-based arrangements that MSK organizations have encountered operate at the group, health system, or accountable care organization level, where individual variation is absorbed by aggregation. ASM does not aggregate. Each physician carries a score and each physician receives an adjustment on that physician's own Part B payments. This changes internal governance. Compensation models that do not account for individually assigned adjustments will produce inequity within the group. Physician engagement strategies that rely on group-level reporting will not change behavior, because the physician being asked to change is the physician bearing the consequence.
Second: measurement capability is now infrastructure For most of the last decade, patient-reported outcome measurement in MSK specialty practice has been a research activity, a registry obligation for some, and an optional quality initiative for the rest. ASM converts it into infrastructure, in the same category as the practice management system or the electronic health record. Organizations should budget and staff it accordingly, and should recognize that the capability has value well beyond ASM. Commercial payers, delegated review vendors, and bundled arrangements all increasingly ask for documented functional outcomes. A practice that can produce them holds a negotiating asset.
Third: the model rewards operational maturity, not clinical heroics Nothing in the ASM design rewards technical excellence in the procedure room. It rewards records retrieval that prevents duplicate imaging, scheduling discipline that captures follow-up scores, referral communication that prevents duplicated workup, and site of service decisions that reflect cost as well as convenience. These are administrative capabilities. Organizations whose competitive advantage rests entirely on clinical reputation should recognize that this model does not measure that advantage.
Position on artificial intelligence in ASM operations AI-enabled tooling has legitimate application in ASM operations: identifying patients due for follow-up measurement, surfacing documentation gaps before a note is signed, decomposing episode cost data, and drafting authorization support. GoHealthcare's position is that these applications should be governed under a defined framework covering intended use, validation, monitoring for performance drift, human review of consequential outputs, and documentation retention.
Two applications warrant heightened caution. The first is any tool that stratifies patients in a way that influences which interventions they are offered, because in a model that rewards lower episode cost, a stratification tool can encode utilization suppression as clinical recommendation. The second is any tool generating patient-reported outcome data or imputing missing scores, because the resulting values enter a federal quality measure and, if not genuinely patient-derived, raise data integrity concerns of a different order than a documentation convenience.
Back to guide navigation28
CMS Ambulatory Specialty Model
GoHealthcare Case Study
The following case study is original and educational. It does not describe any actual patient, physician, practice, facility, or organization. Details have been constructed to illustrate operational dynamics rather than to report events.
Clinical scenario A seven-physician musculoskeletal specialty group operates in a metropolitan market. The group comprises three interventional pain physicians, two orthopedic spine surgeons, one neurosurgeon, and one physiatrist, supported by four advanced practice providers. The group owns a single-specialty ambulatory surgery center. Approximately forty-two percent of professional revenue derives from Medicare fee-for-service.
In February 2026 the practice administrator finds four of the seven physicians on the preliminary ASM participant list: all three interventional pain physicians and one of the two spine surgeons. The neurosurgeon, the physiatrist, and the second spine surgeon do not appear. The administrator initially concludes that the model is a limited exposure affecting a minority of the group.
Documentation challenges A readiness assessment identifies that the group captures numeric pain scores at every visit but captures no validated functional status instrument at any point. Functional descriptions appear in narrative text, typically as a phrase in the history of present illness. Depression screening is performed inconsistently and recorded in a scanned document rather than a structured field. Body mass index is captured reliably. Medication reconciliation is complete but does not flag high-risk medications in patients over sixty-five in any systematic way.
The assessment also finds that the group's own prior authorization denial log contains the answer. Over the preceding twelve months, the most common denial reason for repeat radiofrequency ablation requests was absence of documented functional improvement following the prior procedure. The practice was already failing to produce the exact data the ASM quality measure requires, and was already losing revenue for it.
Prior authorization barriers The group's authorization team maintains a high approval rate but achieves it through labor. Approximately one in five submissions requires supplementary records retrieval after initial submission, most commonly to obtain outside imaging or documentation of prior conservative therapy from referring practices. Peer-to-peer reviews average two per week, concentrated in advanced imaging and in neuromodulation trial requests.
Payer considerations The group navigates Medicare local coverage determinations, two delegated review vendors under different commercial contracts, and a Medicare Advantage population with its own criteria. Each has distinct conservative therapy documentation expectations. The team maintains separate submission templates for each. None of the templates requires a validated functional status instrument, which is one reason the practice never built the capability.
Operational workflow The administrator reframes the project after performing the financial exercise described in Section 12. Nine percent of the four participating physicians' Medicare Part B professional payments exceeds the group's prior-year distributable income by a meaningful margin. Twelve percent, the exposure by the final performance year, exceeds it substantially. The project moves from the quality committee to a working group reporting to the managing partner, with the revenue cycle director as accountable owner and the quality lead as a named contributor.
The working group also revisits the initial conclusion that only four physicians are affected. Three findings change the assessment. First, the final participant list, built on a different claims year, may differ. Second, the physiatrist and the second spine surgeon both participate in the same episodes as the participating physicians, and where either crosses the thirty percent attribution threshold, that episode's cost lands on the participating colleague's score as well. Third, the ambulatory surgery center's case mix and post-acute pathways sit inside those episodes. The exposure is a group exposure even though the adjustment is individual.
Resolution strategy 1. Verify participant status for all seven physicians by TIN and NPI against the current CMS dataset rather than relying on the preliminary list, and re-verify when the final list posts. 2. Select a validated functional status instrument consistent with the measure specification, and implement it group-wide rather than only for participating physicians, because attribution crosses physicians and because the data has independent authorization value. 3. Deploy capture through the patient portal with a tablet fallback at check-in, with front office accountability for completion rate rather than clinician accountability. 4. Build an automated follow-up outreach at the interval specified by the measure, decoupled from whether the patient has a scheduled return visit.
5. Move depression screening into a structured field and add a high-risk medication flag to the reconciliation workflow. 6. Move records retrieval upstream, so outside imaging and referring practice conservative therapy documentation are requested at the time the referral is received rather than at the time authorization is prepared. 7. Approach the four highest-volume referring primary care practices with a draft collaborative care arrangement, reviewed by healthcare regulatory counsel, structured around information flow. 8. Pull the existing MIPS episode-based cost measure feedback for low back pain and decompose episode spending by service category to identify the largest reducible component. 9. Adopt a written governance statement, approved by clinical leadership, confirming that cost performance does not override clinical judgment, and distribute it to all clinicians. 10. Submit a comment on the CY 2027 proposed rule before September 14, 2026, describing the group's specific functional status capture constraints with supporting volume data.
Outcome By the fourth month of implementation, functional status capture at baseline reaches seventy-eight percent of eligible new evaluations, with follow-up capture at fifty-one percent. Follow-up capture is identified as the constraint and outreach is moved from portal message to staff telephone call for non-responders, which raises follow-up capture to sixty-nine percent by month seven.
The upstream records retrieval change produces an unanticipated second benefit. Supplementary records requests during authorization review fall by roughly half, reducing authorization cycle time and reducing the duplicate imaging that had been ordered when outside studies could not be located. Episode cost decomposition confirms diagnostic imaging as the second-largest reducible category after post-acute utilization.
Repeat radiofrequency ablation denials citing absence of documented functional improvement decline substantially once the follow-up score becomes routinely available for submission. The group realizes measurable authorization revenue benefit more than two years before the first ASM payment adjustment takes effect.
Lessons learned • The financial framing changed organizational behavior. The measure specifications did not. • The group's own denial log identified its ASM vulnerabilities more accurately and faster than any external assessment. • Implementing capture group-wide rather than only for identified participants proved correct, because attribution crosses physicians and because the final participant list differs from the preliminary one. • Follow-up capture, not baseline capture, was the binding constraint. Practices should instrument the follow-up step from the beginning. • The changes made for ASM produced authorization benefit immediately, which sustained internal support during a two-year period with no direct ASM feedback. • Assigning ownership to revenue cycle rather than quality was the highest-leverage decision in the entire effort.
Back to guide navigation29
CMS Ambulatory Specialty Model
GoHealthcare Best Practices
| Domain | Practice | Rationale |
|---|---|---|
| Governance | Assign a single accountable owner in the revenue function, with quality and clinical leadership as named contributors. | Half the score is cost and the adjustment applies to all Part B revenue. Ownership determines framing and framing determines resourcing. |
| Verification | Confirm participant status by TIN and NPI against the current CMS dataset, and re-verify at each list update. | Name-based and secondary-source lookups produce errors, and the list changes between preliminary and final. |
| Measurement | Implement functional status capture group-wide rather than only for identified participants. | Attribution crosses physicians within a group and the participant list changes. |
| Measurement | Instrument the follow-up capture step from the beginning and report completion rate weekly for the first quarter. | Follow-up capture is the binding constraint in nearly every implementation. |
| Data architecture | Confirm every required element writes to a structured, extractable field before beginning collection. | Narrative capture satisfies the clinical purpose and fails the reporting purpose. |
| Cost | Move records retrieval upstream to the point of referral receipt. | Prevents duplicate imaging, shortens authorization cycle time, and reduces episode cost simultaneously. |
| Cost | Decompose episode spending by service category using existing MIPS feedback before CMS model data arrives. | The methodology is the same and the data is available now. |
| Compliance | Adopt and distribute a written statement that cost performance does not override clinical judgment. | It is the correct clinical position and it is useful evidence of the organization's position. |
| Compliance | Route every collaborative care arrangement and any beneficiary incentive program through healthcare regulatory counsel. | These sit in Anti-Kickback Statute and physician self-referral territory, and waivers protect only conforming arrangements. |
| AI governance | Govern any AI tooling influencing stratification, documentation, or outcome data under a defined framework with human review of consequential outputs. | Stratification tools can encode utilization suppression; imputed outcome data enters a federal quality measure. |
| Advocacy | Comment on rulemaking with specific operational detail and supporting data. | Specific operational objections are more useful to CMS and more persuasive than general opposition. |
| Physician engagement | Report results at the physician level, not the group level. | Adjustments are individual, so behavior change must be prompted individually. |
30
CMS Ambulatory Specialty Model
Implementation Roadmap
The following sequence assumes a practice beginning work in the second half of 2026 for a performance year starting January 1, 2027. Practices beginning later should compress the assessment phase rather than the capture build, because capture reliability is the element that most requires elapsed time.
| Phase | Window | Actions | Deliverable |
|---|---|---|---|
| Assessment | Weeks 1 to 3 | Verify participant status by TIN and NPI. Pull twelve months of denial reasons and peer-to-peer triggers. Pull existing MIPS episode-based cost measure feedback for low back pain. Model nine and twelve percent exposure against operating margin. | A written exposure statement and vulnerability assessment presented to practice leadership. |
| Governance | Weeks 3 to 5 | Assign accountable ownership. Establish the working group and monthly review cadence. Adopt the clinical judgment governance statement. | Named owner, meeting cadence, and approved governance statement. |
| Measurement build | Weeks 4 to 14 | Select the functional status instrument. Configure structured fields. Build portal and fallback capture. Build automated follow-up outreach. Move depression screening to a structured field. Add the high-risk medication flag. | Working capture workflow with an end-to-end test submission completed. |
| Cost build | Weeks 6 to 16 | Move records retrieval upstream. Decompose episode spending by category and assign an owner to the largest reducible component. Review site of service pathways against current ambulatory surgery center covered procedures and payment indicators. | Records retrieval workflow live; episode cost decomposition with named owners. |
| Collaboration build | Weeks 8 to 20 | Draft the collaborative care arrangement template. Obtain counsel review. Approach the highest-volume referring primary care practices. Configure the data exchange pathway. | Counsel-reviewed template and at least one executed arrangement. |
| Interoperability | Weeks 10 to 18 | Confirm certified technology status. Verify each objective. Name the attestation owner and establish the documentation file. | Objective-by-objective confirmation and named attestation owner. |
| Advocacy | Before September 14, 2026 | Prepare and submit a comment on the CY 2027 proposed rule with specific operational detail and supporting data. | Submitted comment, retained. |
| Dry run | November to December 2026 | Operate the full workflow as though the performance year had begun. Measure capture rates. Correct the failure points found. | Capture rate baseline and a corrected workflow entering January 1. |
| Performance year one | January 2027 onward | Weekly capture monitoring for the first quarter, monthly thereafter. Quarterly attribution reconciliation and episode cost review. Physician-level reporting. | Operating rhythm with physician-level accountability. |
31
CMS Ambulatory Specialty Model
Frequently Asked Questions
The following questions reflect those most commonly raised by MSK practices. Answers reflect the model as described in published CMS rulemaking and CMS Innovation Center materials as of the publication date.
Q1. Is participation optional? No. Participation is mandatory for physicians who meet the eligibility criteria in a selected geographic area. CMS did not establish an opt-out or a hardship exemption pathway.
Q2. How do I find out whether I am a participant? Check the CMS Ambulatory Specialty Model participant dataset using your Taxpayer Identification Number and National Provider Identifier. Do not rely on name-based lookups or on third-party summaries. The dataset is available at https://data.cms.gov/cms-innovation-center-programs/disease-episode-based- payment-models/ambulatory-specialty-model-participants
Q3. A preliminary list was published in February 2026. Is that final? No. CMS described that list as preliminary and built on calendar year 2024 claims data, and indicated that a final list built on calendar year 2025 data would follow in July 2026. Confirm current status directly with CMS.
Q4. I am a subspecialist whose practice has little to do with low back pain. Am I excluded? Not automatically. Cohort assignment follows the plurality of your Medicare Part B claims, as assigned by your Medicare Administrative Contractor, rather than your self-identified subspecialty or board certification. In the CY 2027 proposed rule CMS proposed exceptions for specialty redesignation and subspecialty-based exclusions, but those are proposals only.
Q5. Are advanced practice providers included? Advanced practice professionals are not individually targeted as ASM participants. Their documentation still matters, because services they furnish appear within the episode and because they frequently capture the screening and functional status data the quality measures require.
Q6. What is the twenty-episode threshold? A physician must have at least twenty attributed low back pain episodes in a twelve-month period, identified using the MIPS episode-based cost measure methodology, to be selected. The threshold also operates within a performance year to determine whether a payment adjustment applies.
Q7. If my volume drops below twenty episodes, am I out of the model? No. Once determined eligible, a physician remains an ASM participant for the duration of the model even if the criteria are no longer met. Published analysis indicates that a participant not reaching twenty attributed episodes in a given performance year continues to be tracked but does not receive a payment adjustment for that year. Confirm this mechanic against the final rule before relying on it.
Q8. What exactly does the payment adjustment apply to? All Medicare Part B covered professional services furnished by the participant during the payment year. It is not limited to low back pain services.
Q9. How large can the adjustment be? Negative nine to positive nine percent for performance years 2027 and 2028, rising through the model to negative twelve to positive twelve percent for performance year 2031.
Q10. When does the first adjustment take effect? Calendar year 2029, based on calendar year 2027 performance. The lag is two years throughout the model.
Q11. Does ASM change coverage or prior authorization requirements? No. Coverage determinations, prior authorization requirements, coding rules, National Correct Coding Initiative edits, and medical necessity standards all continue to operate unchanged. ASM adds a retrospective performance adjustment on top of them.
Q12. How does ASM relate to the WISeR Model? They are separate programs with separate authorities, geographies, and mechanics. WISeR operates prospectively on selected services through prior authorization and pre-payment review. ASM operates retrospectively on episode cost and quality. A practice may be subject to both, neither, or either.
Q13. Do I still have to report MIPS? Participants who satisfy ASM eligibility and data submission requirements for a performance year are exempt from MIPS for that year.
Q14. Does ASM count as an Advanced Alternative Payment Model? No. ASM was not designated as an Advanced APM under MACRA, which means participation does not confer qualifying participant status or the associated conversion factor advantage.
Q15. What are the quality measures for the low back pain cohort? Published analysis of the rulemaking describes five measures: a lumbar spine imaging measure for low back pain; use of high-risk medications in older adults; depression screening and follow-up plan; body mass index screening and follow-up plan; and functional status change for patients with low back impairments. In July 2026 CMS proposed adding a low back pain imaging measure, so the set may change. Confirm the current set against the final rule and the Quality Payment Program specifications.
Q16. Which measure should we build first? Functional status change. It is a patient-reported outcome measure requiring two linked data points per patient, it has essentially no reporting history in the affected specialties, and failure to report produces a score of zero. It also has independent value in repeat procedure authorization.
Q17. What happens if we do not report a required measure? The participant receives a score of zero for that measure. There is no exclusion mechanism that removes the measure from the calculation.
Q18. How are we benchmarked? Against other ASM participants treating the same condition. Quality measures are scored by decile against benchmarks derived from participant performance. Cost is scored against the participant cohort median in standard deviation ranges.
Q19. Can two physicians in my group be attributed the same episode?
Yes. Any clinician in the attributed clinician group who billed at least thirty percent of the trigger or confirming codes during the episode is attributed that episode, and the attribution is not divided between them.
Q20. How long is a low back pain episode? A 120-day attribution window opens at the trigger event and extends when a reaffirming claim demonstrates a continuing care relationship. Published analysis reports a resulting range of 120 to 484 days depending on continuity of care.
Q21. What spending counts toward the episode? Spinal surgeries and procedures; spinal injections and neurostimulators; hospitalizations; imaging, diagnostics, and laboratory services; outpatient visits; post-acute care; therapy services and manipulation; medications; behavioral health and ancillary services; durable medical equipment; patient transport; and telehealth.
Q22. Do improvement activities and interoperability improve my score? Published analyses citing the Federal Register describe both as downside-only scoring adjustments, ranging from zero to negative twenty percent and zero to negative ten percent respectively. At least one specialty society summary describes them as contributing bonus points. GoHealthcare considers the downside-only reading better supported. Confirm against the final rule text.
Q23. Is there any adjustment for small practices? Published analysis describes a scoring adjustment of ten percent for practices of fifteen or fewer clinicians, counting advanced practice providers, and a complex patient adjustment of up to ten percent.
Q24. Can we offer patients incentives to participate in their care? The model reportedly permits in-kind patient engagement incentives valued up to one thousand dollars per beneficiary, enabled by a waiver of certain fraud and abuse provisions. The waiver is narrow and conditional. Any program built on it should be designed and documented with healthcare regulatory counsel.
Q25. Are ambulatory surgery centers participants? No. Participants are individual physicians. Facility spending nonetheless falls inside the episode, so facilities are affected indirectly and materially.
Q26. Should we move cases to our ambulatory surgery center to lower episode cost? Only where the procedure is clinically appropriate in that setting, appears on the ambulatory surgery center covered procedures list, and carries a payment indicator supporting facility payment. Certain services, including unlisted surgical procedures assigned payment indicator U5, generate no Medicare ambulatory surgery center facility payment. Verify current indicators before redesigning a pathway.
Q27. Is it acceptable to reduce procedure volume to improve cost scores? Withholding indicated care to protect a score is clinically indefensible and creates liability and regulatory exposure. The defensible cost levers are waste elimination, evidence-consistent care sequencing, and site of service optimization. GoHealthcare recommends adopting a written governance statement confirming that cost performance does not override clinical judgment.
Q28. What was proposed for ASM in the CY 2027 rule? Reported proposals include participant exceptions for Taxpayer Identification Number changes and specialty redesignations, subspecialty-based exclusions, improvement activities flexibility for small practices, a new low back pain imaging measure, a voluntary patient-reported outcome data submission incentive, a rural adjustment, and clarified quality measure scoring. Comments close September 14, 2026
and none of it is final.
Q29. What can we do right now, before CMS model data arrives? Pull existing MIPS episode-based cost measure feedback for low back pain, which uses the same underlying methodology. Review twelve months of denial reasons and peer-to-peer triggers. Verify participant status. Model the financial exposure. Begin functional status capture.
Q30. Will this model expand to other musculoskeletal conditions? CMS has not announced expansion. The trajectory of Innovation Center rulemaking, and commentary from surgical societies noting that most surgical care is delivered in the outpatient setting, both suggest that models targeting ambulatory specialty care are likely to grow. Practices should treat the low back pain cohort as a template rather than an endpoint.
Back to guide navigation32
CMS Ambulatory Specialty Model
Key Takeaways
• ASM is mandatory, individual, and two-sided. There is no opt-out and no hardship exemption pathway, and participation is durable once established. • Six musculoskeletal specialties constitute the low back pain cohort, which is the larger of the two cohorts on the preliminary list. • The adjustment applies to all Medicare Part B professional services, not only to low back pain services, which is the single most consequential design feature. • Quality and cost each carry fifty percent of the score. Improvement activities and promoting interoperability are best understood as compliance obligations rather than performance opportunities. • The functional status change measure is the largest capability gap and should be the first build. It also strengthens repeat procedure authorization independently of ASM. • Episode cost captures nearly the entire MSK procedure inventory: injections, ablation, neuromodulation, augmentation, decompression, fusion, imaging, therapy, post-acute care, and durable medical equipment. • Attribution is not divided. Two physicians can each carry the full cost of the same episode, which makes care team design a scoring decision. • Prior authorization and ASM apply pressure to the same procedures from opposite directions on different timelines, and the disciplines that succeed in one largely succeed in the other. • Several published scoring parameters derive from the proposed rule rather than the final rule, and several elements are under active proposal in the CY 2027 rulemaking. Verify before relying. • The two-year lag means calendar year 2027 conduct is already determining calendar year 2029 revenue. There is no retroactive correction.
Back to guide navigation33
CMS Ambulatory Specialty Model
Future Outlook
Near term, through the end of 2026 • The CY 2027 final rule, expected around November 1, 2026, will resolve the proposed refinements including the possible addition of a low back pain imaging measure and the proposed voluntary patient-reported outcome incentive. • The final participant list determines who is actually exposed. Practices should expect movement in both directions relative to the preliminary list. • Specialty society advocacy continues. The American College of Surgeons, the American Society of Anesthesiologists, and AMGA have each raised structural objections that CMS has not addressed.
Medium term, 2027 through 2029 • Performance year one generates the first benchmark distribution. Because benchmarks derive from participant performance, the first year establishes the reference point against which subsequent years are measured. • The proposed sunset of traditional MIPS reporting in 2029 and the transition toward MIPS Value Pathways will make condition-specific measure sets the norm rather than the exception. • The first payment adjustments in 2029 will make the model's financial reality concrete and are likely to drive a second wave of operational investment among practices that deferred.
Longer term • Expansion to additional conditions or additional specialties is plausible given the Innovation Center's trajectory from primary care models to facility models to ambulatory specialty models. • Commercial payer adoption of similar episode-based specialist accountability is a reasonable expectation, as commercial programs have historically followed Medicare model design. • Patient-reported outcome capture is likely to become a standing requirement across payers rather than an ASM-specific obligation, which strengthens the case for building it well rather than minimally.
Back to guide navigation34
CMS Ambulatory Specialty Model
References
All references are primary sources or authoritative secondary analysis of primary sources. Where a figure in this guide derives from secondary analysis citing a specific Federal Register page, that derivation is identified in the text.
Centers for Medicare and Medicaid Services Centers for Medicare & Medicaid Services. Ambulatory Specialty Model (ASM). CMS Innovation Center. https://www.cms.gov/priorities/innovation/innovation-models/asm Centers for Medicare & Medicaid Services. Ambulatory Specialty Model Frequently Asked Questions. https://www.cms.gov/priorities/innovation/asm-ambulatory-specialty-model-frequently-asked-questions
Centers for Medicare & Medicaid Services. ASM Model Fact Sheet. https://www.cms.gov/files/document/asm-model-fact-sheet.pdf Centers for Medicare & Medicaid Services. ASM Participant Readiness Roadmap. https://www.cms.gov/priorities/innovation/files/asm-participant-readiness-rm.pdf Centers for Medicare & Medicaid Services. ASM Performance Categories Technical Fact Sheet. https://www.cms.gov/priorities/innovation/files/asm-prf-ctg-rpt-fs.pdf Centers for Medicare & Medicaid Services. ASM Mandatory Geographic Areas. https://www.cms.gov/priorities/innovation/files/asm-mandatory-geo-areas.xlsx Centers for Medicare & Medicaid Services. Ambulatory Specialty Model Participants dataset. https://data.cms.gov/cms-in novation-center-programs/disease-episode-based-payment-models/ambulatory-specialty-model-participants Centers for Medicare & Medicaid Services. Calendar Year 2027 Medicare Physician Fee Schedule Proposed Rule fact sheet. https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2027-medicare-physician-fee-schedule-proposed-rule Centers for Medicare & Medicaid Services. Quality Payment Program: MIPS Value Pathways. https://qpp.cms.gov/mips/mips-value-pathways Centers for Medicare & Medicaid Services. Low Back Pain Episode-Based Cost Measure, Measure Information Form. https://qpp.cms.gov/docs/cost_specifications/2025-06-py2025-mif-ebcm-low-back.pdf Centers for Medicare & Medicaid Services. Specifications for Lumbar Spine Imaging for Low Back Pain Measure. https://www.cms.gov/files/document/lumbar-spine-imaging-low-back-pain-narrative-specifications.pdf
Centers for Medicare & Medicaid Services. ASM Model Infographic. https://www.cms.gov/files/document/asm-infographic.pdf
Federal Register Medicare and Medicaid Programs; CY 2026 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies. Final rule. Federal Register, November 5, 2025. https://www.federalregister.go v/documents/2025/11/05/2025-19787/medicare-and-medicaid-programs-cy-2026-payment-policies-under-the-physici an-fee-schedule-and-other
Medicare and Medicaid Programs; CY 2026 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies. Proposed rule. Federal Register, July 16, 2025. https://www.federalregister.gov /documents/2025/07/16/2025-13271/medicare-and-medicaid-programs-cy-2026-payment-policies-under-the-physicia n-fee-schedule-and-other
Medicare and Medicaid Programs; CY 2027 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies. Proposed rule. Federal Register, July 16, 2026. https://www.federalregister.gov /documents/2026/07/16/2026-14327/medicare-and-medicaid-programs-cy-2027-payment-policies-under-the-physicia n-fee-schedule-and-other
Professional societies and specialty organizations
American Society of Anesthesiologists. Ambulatory Specialty Model (ASM). https://www.asahq.org/advocating-for-you/ambulatory-specialty-model American Society of Regional Anesthesia and Pain Medicine. CMS Releases Preliminary Participant List for Ambulatory Specialty Model. February 12, 2026. https://asra.com/news-publications/asra-update-item/asra-updates/2026/02/12/c ms-releases-preliminary-participant-list-for-ambulatory-specialty-model
American College of Surgeons. New Ambulatory Specialty Model Takes Effect in 2027. ACS Bulletin, January 2026. https:/ /www.facs.org/for-medical-professionals/news-publications/news-and-articles/bulletin/2026/january-2026-volume-111- issue-1/new-ambulatory-specialty-model-takes-effect-in-2027/ American College of Cardiology. Ambulatory Specialty Model for Heart Failure. https://www.acc.org/Tools-and-Practice-Su pport/Advocacy-at-the-ACC/Advocacy-Priorities/Support-Clinicians-in-Providing-Equitable-Value-Based-Care/Ambulator y-Specialty-Model-For-Heart-Failure
AMGA. 2027 CMS Proposed Physician Fee Schedule Rule Illustrates Need for Systemic Reforms. July 2026. https://www.a mga.org/about-amga/newsroom/press-releases/2026/july/2027-cms-proposed-physician-fee-schedule-rule-illustrates- need-for-systemic-reforms American Hospital Association. CMS issues CY 2027 physician fee schedule proposed rule. July 14, 2026. https://www.aha.org/news/headline/2026-07-14-cms-issues-cy-2027-physician-fee-schedule-proposed-rule
Heart Rhythm Society. CMS Publishes Calendar Year 2027 Medicare Physician Fee Schedule Proposed Rule. https://www.hrsonline.org/resource/hrs-publishes-cy2027-mpfs-proposed-rule/
Analytical and legal commentary Champagne N, Mirchandani H, Rubin D. The continued evolution of CMS's mandatory models: The Ambulatory Specialty Model (ASM). Milliman, November 20, 2025. https://www.milliman.com/en/insight/evolution-cms-mandatory-models-ambulatory-specialty-asm Benesch. CMS Finalizes Mandatory Ambulatory Specialty Model for Heart Failure and Low Back Pain Specialists. https://w ww.beneschlaw.com/insight/cms-finalizes-mandatory-ambulatory-specialty-model-for-heart-failure-and-low-back-pain- specialists/ Bass, Berry & Sims PLC. CMS Launches Mandatory Two-Sided Risk Model for Specialists Treating Heart Failure and Low Back Pain. https://www.bassberry.com/news/cms-launches-mandatory-two-sided-risk-model-for-specialists-treating-he art-failure-and-low-back-pain/ Sheppard Mullin Richter & Hampton LLP. CMS Finalizes Mandatory Ambulatory Specialty Model for Cardiology and Low-Back Pain. November 2025. https://www.sheppardhealthlaw.com/2025/11/articles/centers-for-medicare-and-medi caid-services-cms/cms-finalizes-mandatory-ambulatory-specialty-model-for-cardiology-and-low-back-pain/
Epstein Becker Green. Ambulatory Specialty Model Final Rule: Bringing Specialists into Value-Based Payment. https://ww w.ebglaw.com/insights/publications/ambulatory-specialty-model-final-rule-bringing-specialists-into-value-based-paym ent Holland & Knight. CMS Issues CY 2027 Medicare Physician Fee Schedule Proposed Rule. July 2026. https://www.hklaw.co m/en/insights/publications/2026/07/cms-issues-cy-2027-medicare-physician-fee-schedule-proposed-rule
McDermott+. CMS Releases CY 2027 Physician Fee Schedule Proposed Rule. https://www.mcdermottplus.com/insights/cms-releases-cy-2027-physician-fee-schedule-proposed-rule/ McDermott+. The Ambulatory Specialty Model: Officially coming your way in 2027. November 20, 2025. https://www.mcdermottplus.com/blog/regs-eggs/the-ambulatory-specialty-model-officially-coming-your-way-in-2027/ Forvis Mazars. What Physicians Should Know About CMS' Ambulatory Specialty Model. https://www.forvismazars.us/forsights/2026/01/what-physicians-should-know-about-cms-ambulatory-specialty-model
CliftonLarsonAllen. Physicians Mandated to Be in Ambulatory Specialty Model. https://www.claconnect.com/en/resources/blogs/health-care/physicians-mandated-to-be-in-ambulatory-specialty-model Applied Policy. CMS Issues CY 2027 Physician Fee Schedule Proposed Rule. https://www.appliedpolicy.com/cms-issues-cy -2027-physician-fee-schedule-proposed-rule-with-reduced-physician-payment-rates-telehealth-expansions-and-mssp-r eforms/
Back to guide navigation35
CMS Ambulatory Specialty Model
Reading Recommendations
For practices building ASM capability, GoHealthcare recommends the following reading sequence.
1. Start with the CMS ASM model page. It is short, authoritative, and current, and it links to the participant dataset, the geographic areas file, the readiness roadmap, and the performance categories technical fact sheet. https://www.cms.gov/priorities/innovation/innovation-models/asm 2. Read the CMS ASM Participant Readiness Roadmap. It is written for practices rather than for policy analysts and it is the closest thing to an official implementation guide. 3. Read the low back pain episode-based cost measure information form. This is where episode triggers, attribution windows, reaffirming claims, and the thirty percent threshold are actually defined. Most misunderstandings about ASM trace back to not having read this document. 4. Read the ASM sections of the CY 2026 final rule directly for any parameter that will drive a financial or structural decision. Secondary summaries frequently reproduce proposed rule figures. 5. Read the CY 2027 proposed rule ASM provisions before the September 14, 2026 comment deadline. 6. Read your own specialty society's ASM position. The American Society of Anesthesiologists, the American College of Surgeons, and the American Society of Regional Anesthesia and Pain Medicine have each published analysis specific to the low back pain cohort. 7. Read the Milliman analysis for the clearest published explanation of score construction, cost benchmark ranges, and the incentive pool mechanics, with Federal Register page citations that allow verification.
Back to guide navigation36
CMS Ambulatory Specialty Model
Related GoHealthcare Resources
The following resources in the GoHealthcare MSK Specialty Procedure Library address procedures and operational topics that fall inside the low back pain episode and therefore inside ASM cost measurement.
| Category | Related guides |
|---|---|
| Epidural steroid injections | Caudal, cervical interlaminar, thoracic interlaminar, lumbar interlaminar, cervical transforaminal, thoracic transforaminal, lumbar transforaminal, and sacral transforaminal epidural steroid injection guides |
| Facet joint interventions | Facet joint injection, medial branch block, and radiofrequency ablation guides |
| Neuromodulation | Spinal cord stimulation trial and permanent implantation, dorsal root ganglion stimulation, peripheral nerve stimulation trial and permanent implantation, intrathecal pain pump trial, permanent implantation, and replacement guides, and the Neuromodulation Prior Authorization Process Guide |
| Minimally invasive spine | MILD, Vertiflex and Superion interspinous spacer, PILD, and interspinous spacer guides |
| Vertebral augmentation and ablation | Kyphoplasty, vertebroplasty, and basivertebral nerve ablation guides |
| Lumbar spine surgical | Microdiscectomy, laminectomy, laminotomy, foraminotomy, PLIF, TLIF, ALIF, XLIF, OLIF, and revision lumbar fusion guides |
| Diagnostic imaging | MRI Diagnostic Imaging guide and Foundations Training Tier version |
| Durable medical equipment | DMEPOS and spinal orthoses guide and Foundations Training Tier version |
| Ambulatory surgery center operations | ASC prior authorization, ASC documentation requirements, implant authorization, medical device coverage, same-day surgery documentation, site of service and patient status, and Medicare ASC billing guides |
37
CMS Ambulatory Specialty Model
Recommended Downloads
GoHealthcare recommends developing the following companion resources as separately maintained documents rather than embedding them in this guide, because each contains content that changes on a cadence independent of this document.
• ASM participant verification worksheet. A one-page instrument for confirming each physician's status by TIN and NPI, with a re-verification date field. • ASM financial exposure calculator. A spreadsheet implementing the worksheet in Section 12 across a physician roster. • Functional status capture implementation checklist. A build checklist derived from Section 18, with owner and completion date fields. • Collaborative care arrangement template. A counsel-reviewable draft implementing the minimum content in Section 20. • Episode cost decomposition template. A reporting template for categorizing episode spending by the service categories in Section 7. • ASM and prior authorization crosswalk. A one-page reference mapping the disciplines in Section 16 to the practice's existing authorization workflows. • Quality measure capture audit tool. A monthly audit instrument for completion rate by measure, physician, and location. • Clinical judgment governance statement. A one-page approved statement confirming that cost performance does not override clinical judgment.
Back to guide navigation38
CMS Ambulatory Specialty Model
Visual Recommendations
The following visuals are recommended for the Knowledge Center web page accompanying this guide and for practice-facing presentation.
| Visual | Purpose | Placement |
|---|---|---|
| Model timeline | Performance years, payment years, and the two-year lag shown on a single horizontal axis. | Near Section 4 |
| Participant eligibility decision tree | Geography, specialty, volume, and billing basis as sequential decision points. | Near Section 6 |
| Episode construction diagram | Trigger event, 120-day attribution window, reaffirming claim, and window extension. | Near Section 7 |
| Attribution illustration | The thirty percent threshold shown across three clinicians, demonstrating undivided attribution. | Near Section 7 |
| Score construction diagram | Quality and cost weighting with improvement activities, interoperability, complex patient, and small practice adjustments shown as modifiers. | Near Section 11 |
| Cost benchmark curve | Standard deviation ranges against points, showing the asymmetry of the favorable tail. | Near Section 9 |
| Two-sided compression diagram | Prior authorization pressure and ASM pressure shown converging on the same procedure set from opposite timelines. | Near Section 16 |
| Functional status capture workflow | Baseline trigger, collection modality, follow-up outreach, structured field, and reporting pathway. | Near Section 18 |
| Episode cost decomposition chart | Service categories as proportional contributors to episode spending. | Near Section 19 |
| Implementation roadmap Gantt chart | Phases, windows, and deliverables from Section 30. | Near Section 30 |
| Financial exposure comparison | Nine and twelve percent of Medicare professional revenue shown against operating margin. | Near Section 12 |
39
CMS Ambulatory Specialty Model
Document History
| Version | Date | Summary of changes | Prepared under |
|---|---|---|---|
| 1.0 | July 31, 2026 | Initial publication. Covers the Ambulatory Specialty Model as finalized in the CY 2026 Medicare Physician Fee Schedule final rule, the February 2026 preliminary participant list, and the ASM refinements proposed in the CY 2027 Medicare Physician Fee Schedule proposed rule published July 16, 2026. Identifies open verification items including final participant list status, final rule scoring parameters, and the pending CY 2027 rulemaking. | GoHealthcare Practice Solutions, under the leadership of Pinky Maniri, Founder and Chief Executive Officer |
Anticipated revision triggers • Publication of the CMS final ASM participant list.
• Publication of the CY 2027 Medicare Physician Fee Schedule final rule, expected around November 1, 2026. • Any change to the low back pain cohort quality measure set. • Any CMS clarification of improvement activities or promoting interoperability scoring mechanics. • Publication of first performance year benchmark data. • Any announced expansion of the model to additional conditions or specialties.
| Gate | Status |
|---|---|
| Clinical and medical reviewer sign-off | Open |
| Payer policy currency review | Open |
| WISeR status confirmation | Open |
| Legal and counsel review | Open |
| Brand and accessibility review | Open |
40
CMS Ambulatory Specialty Model
Educational Disclaimer
1. Purpose and limitation of this document This document is published by GoHealthcare Practice Solutions, under the leadership of Pinky Maniri, Founder and Chief Executive Officer, for educational and operational reference purposes only. It is intended to assist healthcare professionals in understanding the operational, documentation, payer policy, and revenue cycle implications of the Centers for Medicare & Medicaid Services Ambulatory Specialty Model. It is not a clinical practice guideline, a procedural technique manual, a physician training resource, an actuarial analysis, or official guidance from any government agency.
2. No professional relationship created Use of this document does not create a consulting, advisory, attorney-client, physician-patient, or other professional relationship between the reader and GoHealthcare Practice Solutions or any of its personnel. Readers requiring advice specific to their circumstances should engage appropriate professional advisors directly.
3. Not clinical advice Nothing in this document should be construed as clinical advice or as a recommendation regarding the care of any individual patient. Clinical decisions remain the exclusive responsibility of the treating clinician exercising independent professional judgment. In particular, no statement in this document regarding episode cost, utilization, or performance measurement should be interpreted as a recommendation to withhold, delay, or limit clinically indicated care.
4. Not legal advice This document does not constitute legal advice. Discussion of collaborative care arrangements, beneficiary engagement incentives, fraud and abuse waivers, safe harbors, and related regulatory questions is informational only. Arrangements described in this document should be reviewed by qualified healthcare regulatory counsel before implementation.
5. Not actuarial or financial advice Financial exposure frameworks in this document are simplified illustrations intended to make magnitude visible to practice leadership. They are not actuarial estimates, financial projections, or investment advice, and they should not be relied upon for budgeting, valuation, transaction, or financing decisions without independent professional analysis.
6. Payment model content and verification Payment model design elements described in this document are drawn from Centers for Medicare & Medicaid Services rulemaking, CMS Innovation Center publications, and authoritative secondary analysis available as of the publication date. Several parameters described in published analysis derive from proposed rather than final rulemaking, and additional refinements were under active proposal as of the publication date. Model design, participant lists, quality
measure sets, scoring parameters, and payment mechanics are subject to change. All content must be verified against current primary sources before being relied upon.
7. Coding and billing limitations Any coding, billing, or documentation content in this document is general and educational. Code assignment must reflect the specific services actually furnished and documented in the medical record. Submission of claims that are not supported by the medical record may give rise to liability under the False Claims Act, the civil monetary penalties provisions of the Social Security Act, the Anti-Kickback Statute, and the physician self-referral law, as well as under applicable state law. Nothing in this document should be interpreted as authorizing or encouraging the submission of any claim not fully supported by documentation.
8. Coverage and payer policy Coverage policies, medical necessity criteria, prior authorization requirements, and utilization management criteria change frequently and vary by payer, product, plan, geography, and effective date. Content in this document reflects publicly available information as of the publication date and may not reflect the requirements applicable to any particular patient, plan, or claim. Verify all requirements directly with the applicable payer before rendering or submitting services.
9. Payer content and automated processing Summaries of payer, vendor, and utilization management organization positions in this document reflect synthesis of publicly available information and may have been developed with the assistance of automated or artificial intelligence processing. Such summaries are not reproductions of payer policy documents and should not be substituted for review of the applicable policy in its current form.
10. Artificial intelligence assisted authorship This document was developed with the assistance of artificial intelligence tools under human editorial direction and review by GoHealthcare Practice Solutions. Content has been reviewed for accuracy against primary sources. Readers should nonetheless verify all regulatory, coverage, coding, and payment content against current primary sources before relying upon it.
11. Artificial intelligence governance Where this document discusses the use of artificial intelligence or machine learning in healthcare operations, it does so at a general level. Organizations deploying such tools remain responsible for validation, monitoring, human oversight of consequential outputs, documentation, and compliance with applicable law, regulation, accreditation standards, and payer requirements.
12. Prohibition on use for model training This document may not be used, in whole or in part, to train, fine-tune, evaluate, or otherwise develop any artificial intelligence or machine learning model, nor incorporated into any dataset for such purposes, without the express prior written permission of GoHealthcare Practice Solutions.
13. Third-party content and trademarks References to third-party organizations, payers, vendors, professional societies, and government agencies are for identification and educational purposes only and do not imply endorsement, affiliation, sponsorship, or approval. All trademarks, service marks, and registered marks are the property of their respective owners. CPT is a registered trademark of the American Medical Association.
14. External links Website addresses provided in this document were believed accurate as of the publication date. GoHealthcare Practice Solutions does not control and is not responsible for the content, availability, or accuracy of any external website.
15. Limitation of liability GoHealthcare Practice Solutions makes no representation or warranty, express or implied, regarding the accuracy, completeness, currency, or fitness for any particular purpose of the content of this document, and disclaims all liability for any loss or damage arising from reliance upon it to the fullest extent permitted by law.
16. Corrections GoHealthcare Practice Solutions welcomes correction. Readers identifying an inaccuracy in this document are invited to submit it through https://www.gohealthcarellc.com so that it may be reviewed and the document revised. Corrections are applied promptly and recorded in the Document History.
Back to guide navigationConnected GoHealthcare Operating System
The Eight Excellence Frameworks™
Open the complete GoHealthcare framework pages connected to this operational guide.
01
Patient Access Excellence Framework™
Open Framework 02Clinical & Utilization Excellence Framework™
Open Framework 03Practice Operations Excellence Framework™
Open Framework 04Regulatory, Risk & Compliance Excellence Framework™
Open Framework 05Revenue Cycle & Integrity Excellence Framework™
Open Framework 06Technology, Data & AI Excellence Framework™
Open Framework 07Performance Intelligence Excellence Framework™
Open Framework 08Leadership & Governance Excellence Framework™
Open FrameworkReview the complete Eight Excellence Frameworks™ operating system
Strengthen ASM Readiness Across Your MSK Organization
GoHealthcare Practice Solutions supports musculoskeletal specialty practices with prior authorization, operational readiness, documentation, payer intelligence, and revenue cycle strategy.
Developed By
Pinky Maniri
MSc, BSc, CRCR, CSAPM, CSPPM, CSBI, CSPR, CSAF, Certified in Healthcare A.I. Governance
Founder and Chief Executive Officer, GoHealthcare Practice Solutions