Data Submission

PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program

PPS-Exempt Cancer Hospitals (PCHs) participating in the PCHQR Program must submit required data via each measure's acceptable methods of transmission no later than 11:59 p.m. Pacific Time on the submission deadline date as established by the Centers for Medicare & Medicaid Services (CMS). Only data submitted according to the established submission methods and deadlines set by CMS qualify for inclusion in the PCHQR Program.

The PCHQR Program Submission Deadlines by Due Date document serves as a useful reference and provides specific data submission deadlines for the required PCHQR Program measures by data collection period due date. Reference periods are as follows:

  • Event Date
    • Healthcare-Associated Infections (HAIs), including:
      • Central Line-Associated Blood Stream Infection (CLABSI)
      • Catheter-Associated Urinary Tract Infection (CAUTI)
      • Surgical Site Infection (SSI)
      • Methicillin-resistant Staphylococcus aureus (MRSA)
      • Clostridium difficile (C. diff.)
  • Diagnosis Date
    • Cancer-Specific Treatment measures
  • Patient Treatment or Visit Date
    • Oncology Care Measures (OCMs)
    • Intermediate Clinical Outcome Measures
    • External Beam Radiotherapy (EBRT) for Bone Metastases
    • Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy
    • 30-Day Unplanned Readmissions for Cancer Patients
  • Annual Flu Season - as defined by the Centers for Disease Control and Prevention (CDC)
    • Healthcare Personnel Vaccination (HCP)
  • All other measures denote discharge dates.

For complete measure titles and National Quality Forum designations, refer to the PPS-Exempt Cancer Hospitals Measures page on QualityNet.

Measure Exception Form

Some hospitals may not have locations that meet the National Healthcare Safety Network (NHSN) criteria for CLABSI or CAUTI reporting, and some hospitals may perform so few procedures requiring surveillance under the SSI measure that the data may not be meaningful for Hospital Compare or sufficiently reliable to be utilized for quality reporting purposes in a program year.

Reporting will not be required for the SSI measure if the PCH performed less than a combined total of nine specified colon and abdominal hysterectomy procedures in the calendar year prior to the reporting year. To indicate a measure is not being reported, a Measure Exception Form should be completed and submitted prior to the First Quarter data submission deadline for the applicable program year.

Extraordinary Circumstances Exceptions Form

In the event that a PCH is unable to submit any required information (e.g., medical records, data) due to an extraordinary circumstance, such as a natural disaster, the PCH may request an extension or exception. The PCH will need to complete the Extraordinary Circumstances Exceptions Request Form and submit the form with any required information and supporting documentation within 30 calendar days of the date of the extraordinary circumstance.

These documents must be submitted to the Hospital Inpatient Value, Incentives, and Quality Reporting (VIQR) Outreach and Education Support Contractor via the QualityNet Secure Portal, Secure File Transfer “WAIVER EXCEPTION WITHHOLDING” group. If unable to submit via Secure File Transfer, please submit via email to, or secure fax to 877-789-4443.

PPS-Exempt Cancer Hospitals that are included under a blanket waiver by CMS (due to widespread natural disasters such as hurricanes, tornadoes, etc.) will not be required to submit the Extraordinary Circumstances Exceptions Request Form.

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