Navigating CMS Reporting Requirements
Patient-reported outcomes are becoming central to quality reporting and reimbursement for healthcare organizations. Here’s a snapshot of the ones CODE is tracking.
CMS quality reporting is increasingly tied to patient-reported outcomes (PROs) and in many programs, PRO performance now directly affects reimbursement. New and expanded measures will require hospitals, HOPDs, and ASCs to collect longitudinal outcomes, track patient experience and demonstrate that care delivers real, measurable value to patients.
For leaders searching for clarity on CMS PRO requirements and payment models, the stakes are rising: missed patients, weak capture rates or inconsistent workflows can put revenue at risk. Understanding what’s changing — and planning for reliable, scalable PRO collection, reporting and utilization — is now essential to protect performance, avoid penalties and stay ahead of CMS deadlines.
The below CMS reporting guide summarizes what’s changing, when it matters and how health systems can prepare, so leaders can protect reimbursement, reduce risk and use outcomes data to improve care.
| Program / Measure | Category | Applies to |
|---|---|---|
| THA/TKA PRO-PM | PRO performance measure (PRO-PM) | Hospitals, HOPDs and ASCs |
| Information Transfer PRO-PM | PRO performance measure (PRO-PM) | HOPDs only |
| TEAM (Transforming Episode Accountability Model) | Payment model | Participating hospitals in TEAM markets |
| IOTA (Increasing Organ Transplant Access) | Payment model | Designated kidney transplant hospitals |
| IPFQR + PIX | Quality reporting program + Patient experience survey | Inpatient psychiatric facilities and psych units |
| SDOH 1 & 2 | Screening measures | Acute care hospitals (IQR) |
| Maternity PROs (anticipated) | Emerging PRO area | Hospitals with maternity services |
THA/TKA PRO-PM (Total Hip and Total Knee Arthroplasty)
What is it
The THA/TKA Patient-Reported Outcome Performance Measure (PRO-PM) evaluates whether hospitals, HOPDs and ASCs are systematically capturing patient-reported outcomes before surgery and one year after surgery for total hip and total knee replacements.
Unlike traditional quality measures that focus on complications or utilization, this measure centers on how patients actually feel and function after surgery.
Where it applies
- Inpatient THA/TKA: Currently mandatory
- Outpatient THA/TKA (HOPD and ASC): Voluntary now, moving to mandatory in the near term
Core CMS requirements
To receive full credit for each eligible patient, organizations must:
- Collect both pre-operative and 1-year post-operative PROs
- Achieve a minimum capture rate of 50% (45% for ASCs)
- Ensure surveys are administered using CMS-approved instruments
- Demonstrate consistent, longitudinal follow-up rather than one-time outreach
Why the THA/TKA PRO-PM is challenging in practice
Most organizations struggle with this measure because:
- Patients leave the system after surgery and are hard to reach at one year
- Contact information changes over time
- Manual tracking creates gaps and missed patients
- Multiple departments may send duplicate surveys
- Staff often lack bandwidth for sustained follow-up
Without a structured approach, capture rates are unpredictable and year-end reporting becomes high-risk.
High-performing programs typically include:
- Multi-channel outreach (text, email and phone)
- Dedicated follow-up rather than ad hoc clinic staff efforts
- Automated reminders and tracking
- A centralized system to avoid duplicate surveying
- Benchmarking through a national outcomes registry
Why this matters for reimbursement and quality
As CMS ties more payment to outcomes rather than volume, reliable PRO data is becoming essential evidence that care is delivering meaningful benefit to patients. Organizations that can consistently meet capture thresholds reduce reporting risk and gain better insight into recovery trends across surgeons, sites and service lines.
Information Transfer PRO-PM
What it is
The Information Transfer PRO-PM measures whether patients 18+ undergoing procedures in a hospital outpatient department (HOPD) receive clear, personalized recovery information before discharge and whether that information is understandable from the patient’s perspective.
This is one of CMS’s first measures focused on how well hospitals communicate with patients about recovery, not just what happens in the procedure itself.
Participation timeline
- Mandatory reporting begins: January 1, 2027
- Organizations should begin implementation: No later than July 1, 2026 for mandatory participation
Core CMS requirements
- Anonymous collection must be offered to all HOPD patients 18+
- Hospitals must submit a minimum of 300 completed surveys per year, maintaining a representative sampling over time.
- Surveys must be sampled and collected throughout the performance period (not concentrated in a short window)
- The measure applies to a broad range of outpatient services, including procedures billed under CPT codes 10004–69990 and specific G-codes (G0104, G0105, G0121, G0260)
What strong programs typically do
- Standardize discharge education across departments
- Build a repeatable process for offering anonymous surveys
- Use multi-channel outreach (text, email, or phone) to reach patients after discharge
- Track completion rates in real time to avoid year-end scrambling
If you are already collecting THA/TKA PRO-PM with CODE, adding Information Transfer is a natural extension. CODE can manage anonymous survey outreach, monitoring and submission readiness with minimal lift from your team. For more details, read: The Information Transfer PRO-PM: What New CMS Requirements Mean for Hospitals
TEAM (Transforming Episode Accountability Model)
What it is
The Transforming Episode Accountability Model (TEAM) is a Centers for Medicare & Medicaid Services (CMS) episodic payment model that holds hospitals financially accountable for the total cost and quality of care for defined surgical episodes for traditional Medicare beneficiaries.
Rather than paying separately for each service, TEAM evaluates performance across the full episode of care – from the procedure through recovery – linking financial incentives to both efficiency and outcomes.
When it applies
TEAM began as an episodic payment model in 2026 and will expand over time to additional procedures and participating hospitals.
How TEAM changes incentives
Under TEAM, hospitals are responsible for:
- Managing total episode costs
- Coordinating care across settings
- Reducing avoidable complications and readmissions
- Demonstrating high-quality outcomes for patients
Performance is assessed using a Composite Quality Score (CQS), which blends clinical outcomes, safety metrics and patient-centered measures.
Why PROs matter in TEAM
Patient-reported outcomes become a critical signal of success in TEAM because they reflect whether care actually improves patients’ pain, function, and quality of life – not just whether complications were avoided or costs were controlled.
Hospitals that can reliably track recovery over time are better positioned to understand performance, identify gaps in care, and strengthen their CQS.
Operational implications for hospitals
To succeed in TEAM, organizations typically need to:
- Align surgeons, care teams and post-acute partners around shared goals
- Standardize pathways across sites and specialties
- Monitor both cost and outcomes throughout the episode
- Maintain consistent, longitudinal follow-up with patients
Why this matters for leaders
TEAM represents a broader shift toward accountability for value rather than volume. Hospitals that invest in coordinated care and reliable outcome data are better prepared to manage financial risk, improve patient experience and perform well under TEAM and future CMS payment models. CODE’s TEAM Guide covers essential details on risk tracks, quality scoring, timelines and reporting obligations.
IPFQR (Inpatient Psychiatric Facility Quality Reporting) + PIX
What it is
The Inpatient Psychiatric Facility Quality Reporting (IPFQR) program requires participating psychiatric hospitals and units to collect and report quality data to CMS. A key component of this program is the Psychiatric Inpatient Experience (PIX) Survey, which captures patients’ perspectives on their care before discharge.
Unlike many clinical measures, IPFQR centers on the patient’s lived experience of psychiatric care, including communication, respect and involvement in treatment decisions.
Where IPFQR applies
- Inpatient psychiatric facilities
- Psychiatric units within general acute care hospitals
- Medicare-certified inpatient psychiatric providers
Core CMS requirements
- PIX collection became mandatory in 2026
- Surveys must be administered prior to discharge
- Patients must be offered the opportunity to respond anonymously
- Data must be collected in a standardized, CMS-aligned way
- Results must be submitted as part of annual IPFQR reporting
Collecting reliable patient experience data in psychiatric settings is uniquely complex. Patients may feel vulnerable about sharing feedback. Without careful workflows, organizations risk low response rates, biased samples or noncompliant processes.
For leaders, IPFQR is not just a reporting requirement. It is an opportunity to better understand how inpatient psychiatric care is experienced and where systems can improve safety, engagement, and outcomes.Learn more: IPFQR Final Rule: What Inpatient Psychiatric Facilities Need to Know
IOTA (Increasing Organ Transplant Access)
What it is
The Increasing Organ Transplant Access (IOTA) model is a mandatory CMS payment model aimed at improving kidney transplant access, equity and outcomes for Medicare beneficiaries. It rewards transplant hospitals for both the number and quality of transplants while reducing disparities in access.
Rather than focusing only on volume, IOTA ties financial incentives to how well centers expand access and support patients across the transplant journey.
Where it applies
- Designated kidney transplant hospitals participating in the model
- Medicare fee-for-service beneficiaries receiving kidney transplants
Core CMS requirements
- Performance is evaluated on access, equity and outcomes
- Hospitals are accountable for care coordination and post-transplant results
- Data submission includes clinical outcomes and patient-centered indicators
- Performance affects payment adjustments under the model
Why this matters
IOTA elevates long-term outcomes as a core accountability metric, not an optional improvement effort. For leaders, the model signals a broader shift: CMS is increasingly tying specialty care reimbursement to sustained outcomes, not just procedural success.
SDOH 1 & SDOH 2 (Social Determinants of Health)
What it is
SDOH 1 and SDOH 2 are CMS measures that require hospitals to screen patients for social needs that may affect health outcomes, such as housing instability, food insecurity, transportation barriers and financial strain.
These measures reflect CMS’s growing recognition that clinical outcomes are shaped not only by medical care but also by the conditions in which people live and recover.
Where it applies
- Acute care hospitals participating in Hospital Inpatient Quality Reporting (IQR)
- In some cases, related outpatient and transitional care settings
Core CMS requirements
- SDOH 1: Screen patients for specific social risk factors
- SDOH 2: Document referrals to appropriate community resources when needs are identified
- Use standardized screening tools aligned with CMS guidance
- Integrate results into care planning and documentation
For organizations, this shift increases the importance of cross-sector collaboration with community partners, care navigators and social services. Hospitals that can connect screening to real support and measure whether it makes a difference will be better positioned for future quality and equity expectations.
Maternity PROs (anticipated direction)
What it is
While CMS has not yet finalized a specific maternity PRO measure, policy signals suggest that patient-reported outcomes in maternity care are likely to become part of future quality reporting expectations.
The focus is expected to extend beyond clinical safety metrics to include how birthing people experience care, recovery and postpartum support.
Where it is likely to apply
- Hospitals and health systems providing maternity services
- Potentially both inpatient and outpatient settings
- Likely tied to existing maternity quality programs over time
What CMS is signaling
- Greater emphasis on patient experience in maternity care
- Interest in measuring physical and emotional recovery postpartum
- Alignment with broader maternal health equity priorities
- Potential linkage to future payment or quality programs
PROs offer a way to capture what traditional metrics miss, like pain, mental health, recovery and overall well-being, after birth.
CMS PRO-PMs, Handled.
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