eCQM: Breast Cancer Screening (CMS 125v5)


eCQM:

Breast Cancer Screening

CMS ID:

CMS 125v5

Measure Type:

Process

MIPS High Priority Measure:

No

Quality ID:

112

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:

73.23%

Description:

Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.

  • Numerator: Women with one or more mammograms during the measurement period or the 15 months prior to the measurement period.
  • Denominator: Women 51-74 years of age with an eligible visit (defined as a signed chart note with one of the following encounter types: Office Visit, Home Visit, Nurse Visit, or Nursing Home Visit) during the measurement period.
    • Denominator Exclusions: Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy or for whom there is evidence of a right and a left unilateral mastectomy.

    • 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 125v5 Breast 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. Determine that the patient falls within the denominator eligible age range (51-74 years of age) for the measure.
  2. Document that a mammogram was performed for the patient either during the measurement period or in the 15 months prior to the measurement period using the suggested workflow detailed in Table 1.
  3. For the purposes of this measure, providers may also use the workflow in Table 1 to document breast cancer screenings that were performed by another clinician.

Table 1. Practice Fusion Suggested Workflow for Documenting Mammogram

Screening performed

Practice Fusion Suggested Workflow

Mammogram

  • In the Screenings/Interventions/Assessments section of the encounter, search for a mammogram screening and select the applicable item. Examples include:

    • Breast mammogram screening (LOINC 24606-6)

    • Right mammogram screening (LOINC 26177-6)

    • Bilateral mammogram screening (LOINC 26175-0)

    • Breast mammogram spot (LOINC 37551-9)

    • Breast mammogram grid (LOINC 37539-4)

  • Record and save the following information in the modal window that opens:

    • Status: Performed

    • Date: Date the screening was performed

Note: only mammograms performed during the measurement year or within the 15 months prior to the measurement year will count towards the measure numerator.

To access a complete list of qualifying screenings and 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.

Additional Measure Information

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

    • Denominator exclusion added for women who self-report as previously having a mastectomy.

    • Age range of Initial Population (which represents the measure Denominator) updated from 40-69 to 50-74 years of age.

    • Numerator timeframe extended from 24 months to 27 months to allow for a 3-month grace period.

    • NQF endorsement added.

  • To be recognized for the denominator exclusion, the patient must have at least one of the following exclusion criteria options recorded in her chart (see Table 2 for appropriate codes):

    • History of bilateral mastectomy, OR

    • Status Post Right Mastectomy AND Status Post Left Mastectomy

Table 2: Example codes for CMS 125v5 Exclusions

Exclusion criteria

Data Codes

History of bilateral mastectomy

  • History of bilateral mastectomy (ICD-10 Z90.13)

Status Post Right Mastectomy

  • Acquired absence of right breast and nipple (ICD-10 Z90.11)

Status Post Left Mastectomy

  • Acquired absence of left breast and nipple (ICD-10 Z90.12)

More Information

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