Appendix B

Appendix B
Note: * There is not a need to add contractor’s information to the web applications.

⁺ Submitted under the Hospital IQR program. We are using a standard ECE form that

would apply across all quality reporting programs.

Table A. Summary of PCHQR Information Collection Forms
Forms Submitted with the 2015 IPPS/LTCH PPS Final Rule PRA Package		Note
Program/ Procedural Requirements	Measures Exception Paper-Based*	Updated to reflect contractor’s information
	NOP Paper-Based*
	DACA Paper-Based*
	Extraordinary Circumstances Exception (ECE) Paper-Based and Web application+	Newly proposed program and measure requirements
Measure Requirements	EBRT Measure Data Collection Paper-Based and Web Application
	EBRT Measure Sampling Paper Based and Web Application
	SCIP Data Collection Paper-Based	Updated to reflect contractor’s information
	Oncology Care Measures Data Collection Paper-Based
	SCIP Measures Sampling Paper-Based and Web Application	Newly proposed program requirements
	Oncology Care Measures Sampling Paper-Based and Web Application

Table B. Frequency of Data Collection
	Form	Frequency
Program/ Procedural Requirements	Measures Exception	Annually
	NOP
	DACA
	Extraordinary Circumstances Exception (ECE)	Dependent on the situation
Measure Requirements	OCM	Annually
	EBRT
	Cancer Specific Treatment*
	CLABSI and CAUTI*
	SCIP	Quarterly
	SSI
	HCAHPS

Note: *No forms have been submitted for these measures because CMS leverage with

the ACoS and CDC in obtaining data files from these entities.