Exclusive Deals & Big Savings.
Starting January 1, 2027, the Ambulatory Specialty Model will change how CMS pays selected Medicare specialists. So, if you are a cardiologist, orthopedic surgeon or pain management specialist, this may directly affect your practice’s revenue. The model focuses specifically on quality and cost of care for patients with heart failure and low back pain.
If you are selected you will be required to participate, and you may see an increase or decrease in payments of up to 9% for Medicare Part B payments during the initial 2 years of payment. Here is what you need to know about how it works, who will qualify and how to prepare for.
What You Will Learn
The Ambulatory Specialty Model is a payment model designed by the CMS Innovation Center. It was finalized in the CY 2026 Physician Fee Schedule Final Rule and will operate over 5 performance years from 2027-2031.
The rationale behind this model is that specialist decisions in an outpatient setting can impact the progression of a chronic condition and therefore how much Medicare pays. CMS wants to explore whether holding these specialists accountable for providing high-quality, low cost care will reduce costs without compromising patient care. Official resources can be found on the CMS ASM model page.
The CMS ASM FAQ outlines that there are 3 objectives to this model:
Low value procedures provide little benefit, or have greater risk than benefit.
CMS says voluntary models lose providers over time and tend to attract the ones who already do well. A mandatory model gives a wider and fairer picture and includes physicians who have never been in a value-based program.
Because both are common and expensive in Original Medicare. The final rule estimates that ASM participants will treat about 600,000 episodes a year for roughly 550,000 beneficiaries, with about $2.8 billion in episode spending. You can find the numbers in the final rule.
Both conditions also vary a lot in how doctors treat them. That gap is exactly what CMS wants to measure.
CMS splits the model into two groups, called cohorts.
Specialty is determined by CMS from Medicare Part B claims using relevant specialty codes.
If you are a Cardiologist or Orthopedic Surgeon, this does not necessarily entitle you to take part in ASM. You will still need to meet the criteria on episodes and geographical area.
Non-physician providers such as Nurse Practitioners and Physician Assistants are currently not eligible to take part.
CMS picks participants at the individual physician level and uses a TIN and NPI combination. You are an Ambulatory Specialty Model participant if you meet all four of these:
CMS looks at data from two years before the performance year.
For 2027, it uses 2025 data. It also re-checks eligibility every year. If you stop meeting the criteria, you go back to regular MIPS reporting.
You can check your status in the ASM participants dataset on data.cms.gov.
Every participant gets a final score based on four performance categories:
CMS then compares your score with peers in your own cohort. A cardiologist is ranked against cardiologists. A pain specialist is ranked against others in the low back pain group. You are not scored on a flat pass mark, so your result depends on how others perform too.
You report data and attestations by March 31 after the performance year ends.
For the 2027 performance year that means March 31, 2028. CMS plans to use the Quality Payment Program portal as the same one as used for MIPS.
You will be given an adjustment factor based on your final score. This will then be applied to your Medicare Part B payments for professional services. The score you get in 2027 will affect your payments in 2029.
The adjustment will be -9% to +9% in the first two years of payments (2029 and 2030). It will increase thereafter.
This is often forgotten by many practices. The adjustment impacts all of your professional services in Part B as described by CMS. You need to plan for your full Part B revenue.
Here is the timeline at a glance:
| Year | What happens |
| 2025 | CMS uses this data to decide who is eligible for 2027 |
| 2027 | First performance year begins January 1 |
| March 31, 2028 | Reporting deadline for the 2027 performance year |
| 2029 | First payment adjustments apply to Part B payments |
| 2031 | Last of the five performance years |
| 2033 | Final payment adjustment year |
ASM borrows its framework from MIPS Value Pathways so the measures will look familiar. But it is a different program with its own scoring and payment rules.
| ASM | MIPS | |
| Who takes part | Selected specialists in selected regions | Eligible clinicians under the MIPS rules |
| Focus | Heart failure and low back pain | Broad range of care |
| Participation | Mandatory | Based on MIPS eligibility |
| Scored against | Peers in the same cohort | MIPS scoring rules |
| Reporting portal | QPP portal | QPP portal |
If you are an ASM participant, you are exempt from MIPS reporting in the years you must meet ASM requirements. You also can’t get a MIPS payment adjustment for those years.
One catch. If you are MIPS eligible in 2026, keep reporting to MIPS for 2026, even if you show up on the preliminary ASM list. ASM doesn’t begin until January 1, 2027.
There are a number of challenges that may arise due to the CMS ASM model, particularly in smaller specialty practices.
Practitioners who meet the selection criteria must take part. There is no choice on whether to take part in the scheme like there would be with a voluntary payment model.
The potential for negative adjustments will impact the practitioners’ Medicare Part B eligible revenues. It is important that practices know what the potential impact could be.
Quality, cost, improvement and interoperability data may need to be reported which adds extra work for the billing team.
Some practitioners may not know how many episodes they have been attributed, what their performance measures are or if they are eligible.
Without knowing this information, it can be harder to identify where any gaps in reporting may occur.
Issues may occur if the documentation is incomplete, coding is incorrect or claims data isn’t consistent.
Whilst not all practices may experience a negative adjustment, it is not a good idea to leave preparations until the first reporting deadline.
Start now. Here’s a simple order of work:
If your billing team is already stretched, outside help can take some of the load. P3Care provides ASM reporting support that covers MIPS performance optimization and CMS compliance alignment, which are the same areas the ASM touches.
You can also look at the full range of P3Care services or book a free 30-minute ops audit to see where revenue is leaking before the model starts.
The Ambulatory Specialty Model changes how CMS pays for heart failure and low back pain care. It is mandatory and it carries two-sided risk, and it starts soon.
Check your status, know your numbers and set up your reporting early. For the latest rules and updates, keep the CMS ASM model page bookmarked.
The 2027 Ambulatory Specialty Model brings new reporting responsibilities and financial risks for eligible specialists. Get ahead of these changes with P3Care operations expertise.
Talk to Our Quality Reporting Expert
Yes, if you are in a targeted specialty, meet the 20-episode threshold and practice in a selected geographic area, CMS requires you to take part.
For ASM participants, it is yes and during those years, they must meet ASM requirements. They are exempt from MIPS reporting and cannot receive a MIPS payment adjustment for those years.
The first payment adjustments begin in 2029, based on performance during 2027. The model uses a two years gap between the performance & payment year.
No, CMS currently limits ASM participation to eligible physicians. Nurse practitioners, physician assistants and other non-physician providers are not eligible at this time.
Check the ASM participants dataset on data.cms.gov. It shows which performance years each participant must meet ASM requirements.
By March 31 after the performance year ends. For 2027, the deadline is March 31, 2028.
