CMS-10431 Measure Exception Form

Centers for Medicare & Medicaid Services (CMS)
PPS Exempt Cancer Quality Reporting (PCHQR)
Program
Measure Exception Form
This exception must be renewed at least annually.
Specify the calendar year for Measure exception request(s).
* Indicates required fields
* Measure Exception Information (The exception(s) you are requesting must be selected.)
Select all that apply

Surgical Site Infection (SSI)
Select this option if the hospital performed a combined
total of 9 or fewer colon surgeries and abdominal
hysterectomies in the calendar year prior to the
reporting year.

Calendar Year prior to Reporting Year

Number of Procedures Performed

Exclusion Requested for Calendar Year

Other (Please Describe) If additional space is required,
please attach additional documentation

Calendar Year prior to Reporting Year

Number of Procedures Performed

Exclusion Requested for Calendar Year

Specified colon and abdominal hysterectomy surgical procedures:
Only hospitals that performed 9 or fewer of any of the specified colon surgeries and abdominal hysterectomies
combined in the calendar year prior to the reporting year. The NHSN Operative Procedure Category Mappings to
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Codes (Table 1
extract) is located on the NHSN website.

Last Revised 2/1/2013

Facility Contact Information
*CMS Certification Number (CCN):

*Facility Name:

*CEO/Designee Last Name:

*CEO/Designee First Name:

*Title:

*CEO/Designee E-Mail Address:

*CEO/Designee Telephone Number:

Ext.:

Additional Comments

I hereby certify that the facility meets the exception criteria and therefore has no data to submit related
to the specified measure(s)
Name ___________________________________
Position _________________________________
Date_________________________

Complete and submit the Measure Exception via My QualityNet to “Global Exchange Groups”, “PPSExempt Cancer Hosp. QR Support”;

PRA Disclosure Statement
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 XXXX-XXXX. The time required to complete
this information collection is estimated to average 10 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 21244-1650.

Last Revised 2/1/2013