Under ASM, you may be accountable for an MRI you didn't order

This isn’t a hypothetical. It’s already happening to this cohort.

We analyzed the CMS 2024 Quality Payment Program data for the 37,825 clinicians in the 6 low back pain cohort specialties. Q492, a risk-standardized heart failure admission measure, appeared on the 2024 records of 11,442 of them. 30% of spine and pain specialists are already being scored on a cardiology outcome measure, presumably through the multispecialty tax IDs they bill under, at a mean of 5.49 points out of 10. 30% are at 3 points or fewer.

A pain management physician carrying a heart failure admission measure because of who shares their tax ID is what claims attribution machinery produces. Under MIPS, that oddity is diluted inside a group score. Under ASM, the same machinery points at lumbar imaging, the score is individual, and the payment adjustment is two-sided.

What the design gets right, and what it doesn't answer

To CMS' credit, the Proposed Rule provides that measures without a valid benchmark are removed from the quality score rather than assigned . That addresses one version of the fairness concern.

It fails to address this one: A clinician who manages imaging conservatively can absorb the consequences of a colleague's ordering pattern, with no reporting decision, no measure selection, and no visibility until the score arrives.

There is also a practical asymmetry. Because the measure is claims-computed, no practice can calculate its own baseline until CMS publishes the technical specifications. The agency says that will come in Fall 2026, after the Final Rule. The accountability starts Jan. 1, 2027. The ability to see where you stand arrives, at best, weeks before it.

Three things to do about it

1. Comment. The rulemaking window closes Sept. 14, 2026 at www.regulations.gov. The multi-clinician attribution design and the specification timeline are both legitimately contestable, and this is the only point at which comment can still shape the Final Rule.
2. Audit your own ordering. Pull 12 months of lumbar MRI orders across your roster, because the lookback will. It’s the only baseline available before the specifications publish.
3. Map your attribution exposure. Know which clinicians share TINs with high-imaging colleagues. Under this design, their patterns become your risk.

National data tells you how the machinery behaves. It doesn't tell you what it will attribute to your clinicians.

That’s the analysis we’re offering organizations now. Send us your TIN and NPI roster and we’ll show you your cohort eligibility, episode volume, and the claims measures already computed for your clinicians. There’s no cost or obligation.