eCQM: Cervical Cancer Screening (CMS 124v5)


eCQM:

Cervical Cancer Screening

CMS ID:

CMS 124v5

Measure Type:

Process

MIPS High Priority Measure:

No

Quality ID:

309

Eligible for Quality Programs:

  • Merit-Based Incentive Payment System (MIPS)
  • Medicaid EHR Incentive Program (Meaningful Use)
  • Comprehensive Primary Care Plus (CPC+)

Performance Benchmark for MIPS:

69.00%

Description:

Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:

  • Cervical cytology performed every 3 years.
  • Cervical cytology/human papillomavirus (HPV) co-testing performed during the measurement period or the four years prior to the measurement period for women who are at least 30 years old at the time of the test.

  • Numerator: Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria:

    • Cervical cytology performed during the measurement period or the two years prior to the measurement period for women who are at least 21 years old at the time of the test.

    • Cervical cytology/human papillomavirus (HPV) co-testing performed during the measurement period or the four years prior to the measurement period for women who are at least 30 years old at the time of the test.

  • Denominator: Women 23-64 years of age with an eligible visit (defined in Table 1) during the measurement period.

    • Denominator Exclusions: Women who had a hysterectomy with no residual cervix.

    • Denominator Exceptions: None

eCQM Patient Reports

eCQM Patient Reports can help you identify patient care gaps and improve the performance of your quality measures. Click on the blue result numbers in the eCQM Dashboard to see the patient report for this measure.

The eCQM Patient Reports list the individual patients included in the measure’s population, which measure cohorts the patient is in, and contact information for the patient to streamline any downstream communication that may be needed to fulfill the measure requirements. You can choose to print the patient list for a measure or export it as a CSV.

The measure cohorts included in the eCQM Patient Report for CMS 124v5 Cervical Cancer Screening are:

  • Initial patient population
  • Denominator
  • Numerator
  • Exclusion

Practice Fusion Suggested Workflow
Practice Fusion suggests the following workflow to help ensure that you are able to meet the requirements of this measure within the Practice Fusion EHR.

  1. When seeing a female patient, determine whether she falls within the denominator eligible age range for the measure (23-64 years of age at the time of the visit).
  2. Ensure that the patient has received or receives the appropriate cervical cancer screening (cervical cytology tests or cervical cytology/HPV co-test) within the timeframe described by the measure.
  3. Once the cervical cancer screening is complete, receive or record structured lab results in the Practice Fusion EHR. Cervical cancer screening test codes that will be included in this measure when manually recording structured lab results in the EHR or when receiving structured lab results from connected labs can be found in Table 1.

Table 1: Measure Criteria for CMS 124v5

Data Type

Example Codes

Denominator-eligible encounter types

  • Office Visit
  • Home Visit
  • Nurse Visit
  • Nursing Home Visit

Examples of Cervical Cancer Screenings - HPV Tests

  • Human papilloma virus 18+45 E6+E7 mRNA [Presence] in Cervix by Probe and signal amplification method (LOINC 75694-0)
  • Human papilloma virus 16+18+31+33+35+45+51+52+56 DNA [Presence] in Cervix by DNA probe (LOINC 21440-3)

Examples of Cervical Cancer Screenings - Pap Tests

  • Microscopic observation [Identifier] in Cervix by Cyto stain (LOINC 10524-7)
  • Cytology report of Cervical or vaginal smear or scraping Cyto stain, thin prep (LOINC 47527-7)

To access a complete list of qualifying test codes, visit the United States Health Information Knowledgebase (USHIK). This site is produced by the Agency for Healthcare Research and Quality (AHRQ) in partnership with CMS and the National Library of Medicine (NLM). A free Unified Medical Language System® (UMLS) license, available from NLM, is required to access USHIK.

Note: Only structured lab results with a valid LOINC code can be used to calculate this measure. Lab results that meet the measure criteria will only factor into the measure numerator once they have been signed by the MIPS eligible clinician.

Additional Measure Information

  • This 2016 measure version has been updated from the previous 2015 version specifications, incorporating the following change:

    • Added an HPV/Pap co-test in the past 5 years for women 30-64 years of age to the numerator to align with updated USPSTF guidelines.

    • Added guidance to explain the age ranges in the measure logic and description.

  • To be recognized for the denominator exclusion, the patient must have a qualifying procedure code for a hysterectomy with no residual cervix recorded in her chart. To access a complete list of applicable codes, visit the United States Health Information Knowledgebase (USHIK). This site is produced by the Agency for Healthcare Research and Quality (AHRQ) in partnership with CMS and the National Library of Medicine (NLM). A free Unified Medical Language System® (UMLS) license, available from NLM, is required to access USHIK.

  • To ensure the measure is looking for a cervical cytology test only after a woman turns 21 years of age, the youngest age in the denominator is 23.

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