CMS-10431 OCM Pop Sample paper based

PPS-exempt Cancer Hospital Quality Reporting (PCHQR) Program

Form OCMs_PopSamp_paperbased_ April 17 2014

PPS-exempt Cancer Hosptital Quality Reporitng (PCQR) Program

OMB: 0938-1175

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PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program

Oncology Care Measures (OCM) Paper-Based Form

Online Data Entry Tool Content for FY 2016 and Subsequent Years

Shape2 Shape1 CCN Hospital Name

Instructions: For each measure, (1) Please enter the Total Initial Patient Population and indicate the total Medicare and Non-Medicare populations. (2) Provide the Sample size information. Note: When not sampled, provide only Total Initial Patient Population – Not Sampled.

NQF 0382 Oncology-Radiation Dose Limits to Normal Tissues

NQF 0382 - Sample Frequency: Not Sampled

Not Sampled Patient Population

Number

Total Initial Patient Population


Medicare Initial Patient Population


Non-Medicare Initial Patient Population





NQF 0382 - Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population

Quarter 1

Quarter 2

Quarter 3

Quarter 4

Total

Medicare






Non-Medicare






Total







Sample Size

Sample Size

Quarter 1

Quarter 2

Quarter 3

Quarter 4

Total

Medicare






Non-Medicare






Total












NQF 0383 Oncology: Plan of Care for Pain

NQF 0383 - Sample Frequency: Not Sampled

Not Sampled Patient Population

Number

Total Initial Patient Population


Medicare Initial Patient Population


Non-Medicare Initial Patient Population





NQF 0383 - Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population

Quarter 1

Quarter 2

Quarter 3

Quarter 4

Total

Medicare






Non-Medicare






Total







Sample Size

Sample Size

Quarter 1

Quarter 2

Quarter 3

Quarter 4

Total

Medicare






Non-Medicare






Total











NQF 0384 Oncology: Pain Intensity Quantified


NQF 0384 - Sample Frequency: Not Sampled

Not Sampled Patient Population

Number

Total Initial Patient Population


Medicare Initial Patient Population


Non-Medicare Initial Patient Population



NQF 0384 - Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population

Quarter 1

Quarter 2

Quarter 3

Quarter 4

Total

Medicare






Non-Medicare






Total







Sample Size

Sample Size

Quarter 1

Quarter 2

Quarter 3

Quarter 4

Total

Medicare






Non-Medicare






Total












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

NQF 0389 - Sample Frequency: Not Sampled

Not Sampled Patient Population

Number

Total Initial Patient Population


Medicare Initial Patient Population


Non-Medicare Initial Patient Population



NQF 0389 - Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population

Quarter 1

Quarter 2

Quarter 3

Quarter 4

Total

Medicare






Non-Medicare






Total







Sample Size

Sample Size

Quarter 1

Quarter 2

Quarter 3

Quarter 4

Total

Medicare






Non-Medicare






Total










NQF 0390 Prostate Cancer-Adjuvant Hormonal Therapy for High-Risk Patients


NQF 0390 - Sample Frequency: Not Sampled

Not Sampled Patient Population

Number

Total Initial Patient Population


Medicare Initial Patient Population


Non-Medicare Initial Patient Population



NQF 0390 - Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population

Quarter 1

Quarter 2

Quarter 3

Quarter 4

Total

Medicare






Non-Medicare






Total







Sample Size

Sample Size

Quarter 1

Quarter 2

Quarter 3

Quarter 4

Total

Medicare






Non-Medicare






Total







Please refer to specifications on the PQRS web site:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRS.


Complete and submit the Oncology Care Measures Paper-Based Form via email to:

[email protected].





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 0938-1175. The time required to complete this information collection is estimated to average 15 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, il Stop C4-26-05, Baltimore, Maryland 21244-1850.

PCHQR Program 03/05/2014 Page 1 of 10

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File TitlePPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program Paper-Based Form Online Data Entry Tool Content for FY2016 and Subs
SubjectPPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program Paper-Based Form Online Data Entry Tool Content for FY2016 and Subs
AuthorCMS
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