• 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

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

• For more information on the CMS specifications for this measure, please click here.
• To learn more about the MIPS quality category reporting requirements for 2017, please click here.
• For additional information about quality measures, you may also visit the CMS Quality Payment Programs website and Practice Fusion’s Quality Payment Program Center.