Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Survey
Participation Exemption Request (PER) Form
for the Annual Payment Update for Calendar Year 2026
Use this form to request an exemption from participating in the OAS CAHPS survey for the calendar year (CY) 2026
Annual Payment Update (APU) period based on the number of eligible procedures.
to review and print a hardcopy of the PER form before entering the counts on the online form.
When is the exemption in force? The exemption is in force for the CY 2026 APU period, which
is January 1 through December 31, 2024. The exemption is good for one year.
Facilities must reapply to request an exemption annually.
Who can apply for the exemption? Hospital outpatient departments (HOPDs) that meet OAS CAHPS eligibility
and served fewer than 60 OAS CAHPS survey-eligible patients between January 1 and December 31, 2023
can request an exemption. On an annual basis, CMS reviews all participation exemption requests and makes a determination to approve or deny.
What does the exemption mean? Exempt hospitals do not need to participate in the OAS CAHPS Survey for the CY
2026 APU OAS CAHPS Survey data collection period, which runs from January 1 through December 31, 2024.
This form will assist you in determining if you have fewer than 60 OAS CAHPS-eligible patients.
Instructions for Completing the Participation Exemption Request Form
- Step 1: enter the hospital's 6-digit CCN (CMS Certification Number).
- The system will display the hospital name associated with the CCN from Step 1.
If the hospital name on record is incorrect, please contact your State Survey Agency.
Step 2: enter the number of unduplicated (unique) patients served between January 1,
2023 and December 31, 2023,
who were 18 years old and older who had an eligible surgery or procedure within the OAS CAHPS
eligible range (i.e., CPT- 41 code in the 10004- 69990 range or the following G-codes:
G0104, G0105, G0121 or G0260). Note that a list of excluded CPT codes that should not be included
in the count can be found in the Protocol and Guidelines Manual Appendix P, available on the
OAS CAHPS website (V8.0_OASCAHPS_ProtocolsGuidelinesManual.docx).
Count all patients regardless of payment method (CMS, insurance, or other
method of payment).
To determine the number of unduplicated or unique patients served, count
each patient only once regardless of the number of surgeries or procedures
they received during the specified 12-month period.
1 CPT only copyright 2024 American Medical Association. All rights reserved.
Step 3: Of the patients included in the count in Step 2, enter the
number of patients who fall into each of the categories in Steps 3a through
3g. These patients are not eligible to be included in the OAS CAHPS Survey.
Do not include a patient in more than one category. For example, if
a patient who was served between January 1, 2023 and
December 31, 2023, was
released to hospice, but you know that that patient is deceased, you would
include that patient in the count of patients known to be deceased but not
in the count of those discharged to hospice. For Step 3f.2, you must
provide a brief description of the relevant state laws/regulations and the
number of affected patients until all patients entered in Step 3f.1 have
been accounted for.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0938-1240 with an expiration date of November 30, 2024. The time required to complete this information collection
is estimated to average 8 minutes per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.