CMS-10431 Oncology Care Paper Submission

PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program
Clinical Process/Oncology Care Measures
Paper Submission for FY2016 and Subsequent Years
(NQF 00380) Multiple Myeloma- Treatment with Bisphosphonates
Q1

Q2

Q3

Q4

NUMERATOR
Patient who were prescribed or
received intravenous
biphosphonates within the 12
month reporting period

DENOMINATOR
All patients aged 180 years and
older with a diagnosis of multiple
myeloma, not in remission

(NQF 0382) Oncology: Radiation Dose Limits to Normal Tissues
Q1

Q2

Q3

Q4

NUMERATOR
Patients who had
documentation in medical
record that radiation dose limits
to normal tissues were
established prior to the
initiation of a course of 3D
conformal radiation for a
i i
ft
ti

DENOMINATOR
All patients, regardless of age,
with a diagnosis of pancreatic or
lung cancer who receive 3D
conformal radiation therapy

(NQF 0383) Oncology: Plan of Care for Pain- Medical Oncology and Radiation Oncology
Q1

Q2

Q3

Q4

NUMERATOR

1

Patient visits that included a
documented plan of care to
address pain.
Documented plan of care may
include: use of opioids,
nonopioids analgesics,
psychological support, patient
and/or family education,
referral to a pain clinic, or
reassessment of pain at an
appropriate time interval

DENOMINATOR

All selected surgical patients
with a catheter in place
postoperatively

(NQF 0384) Oncology: Pain Intensity Quantified- Medical Oncology and Radiation
Oncology
Q1

Q2

Q3

Q4

NUMERATOR
Patient visits in which pain
intensity is quantified.
Pain intensity should be
quantified using a standard
instrument, such as a 0-10
numerical rating scale, a
categorical scale, or the
pictorial scale

DENOMINATOR
All visits for patients,
regardless of age, with a
diagnosis of cancer currently
receiving chemotherapy or
radiation therapy

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(NQF 0389) Prostate Cancer: Avoidance of Overuse Measure- Bone Scan for Staging
Low-Risk Patients
Q1

Q2

Q3

Q4

NUMERATOR
Patients who did not have a
bone scan performed any time
since diagnosis of prostate

DENOMINATOR
All patients, regardless of age,
with a diagnosis of prostate
cancer, at low risk of
recurrence, receiving interstitial
prostate brachytherapy, OR
external beam radiotherapy to
the prostate, OR radical
prostatectomy, OR cryotherapy

(NQF 0390) Prostate Cancer: Adjuvant Hormonal Therapy for High-Risk Patients
Q1

Q2

Q3

Q4

NUMERATOR
Patients who were prescribed
adjuvant hormonal therapy
(GnRH) [gonadotropinreleasing hormone] agonist or
antagonist)

DENOMINATOR
All patients, regardless of age,
with a diagnosis of prostate
cancer, at high risk of
recurrence, receiving external
beam radiotherapy to the
prostate

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(*) indicates required for providers participating in the PPS-Exempt Cancer
Hospital Quality Reporting Program
*Facility Name:
*CEO Signature:

*Date:

*CEO Email Address:
Complete and submit the Notice of Participation Agreement form using one of the
following options:
•
•
•

via My QualityNet to the Global Exchange Group “PPS Exempt Cancer Hosp. QR Support
”;
via secure FAX to Program Manager Telligen PCHQR Support (515)-558-5073, or
via mail to:

Telligen PCHQR Support
1776 West Lakes Parkway,
West Des Moines, IA 50266
Attn. Program Manager

DO NOT SEND THE COMPLETED FORM VIA E-MAIL.
Following receipt of the request form, an e-mail acknowledgement will be sent
confirming the form has been received.

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