CMS-10431 Oncology Cares Measures Paper Submission

PPS-exempt Cancer Hospital Quality Reporting (PCHQR) Program (CMS-10431)

PQ 2019-01-29 V1 Data Collection - Oncology Care Measures Paper Form (PC...

PPS-exempt Cancer Hosptital Quality Reporitng (PCQR) Program

OMB: 0938-1175

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PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program

Clinical Process/Oncology Care Measures

Paper Submission for FY2022 and Subsequent Years

(NQF 0210) Proportion of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life

Shape1 Q1 Q2 Q3 Q4



Patients who died from cancer and received chemotherapy in the last 14 days of life.



Patients who died from cancer.

(NQF 0215) Proportion of Patients Who Died from Cancer Not Admitted to Hospice

Shape5 Q1 Q2 Q3 Q4


Proportion of patients not enrolled in hospice.




Patients who died from cancer.


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

Shape9 Q1 Q2 Q3 Q4



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.



All selected surgical patients with a catheter in place postoperatively.

(*) 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 this form via email to: [email protected].

Following receipt of the request form, an email acknowledgement will be sent confirming the form has been received.

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 and expires XX/XX/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 21244-1850.
*****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact James Poyer at (410) 786-2261.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitlePCHQR Clinical Process/Oncology Care Measures
SubjectPCHQR Clinical Process/Oncology Care Measures
File Modified0000-00-00
File Created2021-07-28

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