CMS 124 - Cervical Cancer Screening

Overview

CMS124v8 (2020)
CMS124v9 (2021)
CMS124v10 (2022)

Identifiers

CMS eCQM ID	NQF eCQM ID	NQF	MIPS Quality ID
CMS124v10	–	–	309

*MIE only supports data collection and reporting using eCQM specifications

Definitions

Description	Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: Women age 21-64 who had cervical cytology performed within the last 3 years Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years
Initial Patient Population	Women 23-64 years of age with a visit during the measurement period
Denominator	Equals Initial Population
Denominator Exclusions	Women who had a hysterectomy with no residual cervix or a congenital absence of cervix. Exclude patients who are in hospice care for any part of the measurement period. Exclude patients receiving palliative care during the measurement period.
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 human papillomavirus (HPV) testing performed during the measurement period or the four years prior to the measurement period for women who are 30 years or older at the time of the test
Numerator Exclusions	–
Denominator Exceptions	–

Additional Information

Measure Type	Process measure
Measure Scoring	Proportion measure
Granularity	Patient
Improvement Notation	Higher score indicates better quality
Domain	Effective Clinical Care

Clinical Instructions

New UI Visit Encounter (valid RC202109+)

Original Visit Encounter

Ensure all women aged 23-64 are screened for cervical cancer, at least once within the measurement period. Use the Past Procedures section of the encounter to record a previous HPV or Pap test; otherwise, use the Visit Orders section of the encounter to order/perform one of the recognized procedures (i.e., HPV Test or Pap Test) at the time of the encounter. While documenting the Visit encounter, either record the previous procedure or the receipt of the recognized procedure, or order and perform the test, as appropriate.

1. Option 1: Document in the Past Procedures section
   1. Open the Past Procedures section
   2. Using the Procedure autocomplete, begin typing the name of the diagnostic procedure (e.g., PAP Test, HPV DNA Detection, etc.) with the appropriate Concept ID (e.g., LOINC).
   3. Add the Date and any relevant Notes.
   4. Click the Next button, or close the section
2. Option 2: Document in the Preventive Care section
   1. Open the Preventive Care section
   2. Provide the date of the last reported procedure in the Enter New Date field (e.g., 01-17-2020). This date is the Last Reported Date
   3. Click the Next button, or close the section
3. Option 3: Document in the Tests and Procedures section IF performing the screening in-house
   1. Open the Tests and Procedures section
   2. Using the autocomplete, begin typing the appropriate procedure name
   3. Click the Add to Exam button
   4. After adding the new section, open the procedure section and add any results or findings
   5. Click the Next button, or close the section
4. Continue documenting the encounter, as needed
5. When completed, Close and Archive the encounter

• Option 4: Scan/Index or Upload an accepted Document

  1. Using WebScan , scan and index the appropriate document type configured with the necessary LOIN-C (e.g., 33717-0).

Evidence

Initial Patient Population

Name	Value Set
Encounter, Performed: Home Healthcare Services	2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed: Office Visit	2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed: Online Assessments	2.16.840.1.113883.3.464.1003.101.12.1089
Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up	2.16.840.1.113883.3.464.1003.101.12.1025
Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up	2.16.840.1.113883.3.464.1003.101.12.1023
Encounter, Performed: Telephone Visits	2.16.840.1.113883.3.464.1003.101.12.1080

Denominator Exclusions

Name	Value Set
Assessment, Performed: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)	LOINC Code 71007-9
Diagnosis: Congenital or Acquired Absence of Cervix	2.16.840.1.113883.3.464.1003.111.12.1016
Encounter, Performed: Encounter Inpatient	2.16.840.1.113883.3.666.5.307
Encounter, Performed: Palliative Care Encounter	2.16.840.1.113883.3.464.1003.101.12.1090
Intervention, Order: Hospice care ambulatory	2.16.840.1.113762.1.4.1108.15
Intervention, Performed: Hospice care ambulatory	2.16.840.1.113762.1.4.1108.15
Intervention, Performed: Palliative Care Intervention	2.16.840.1.113883.3.464.1003.198.12.1135
Procedure, Performed: Hysterectomy with No Residual Cervix	2.16.840.1.113883.3.464.1003.198.12.1014

Numerator

Name	Value Set
Laboratory Test, Performed: HPV Test	2.16.840.1.113883.3.464.1003.110.12.1059
Laboratory Test, Performed: Pap Test	2.16.840.1.113883.3.464.1003.108.12.1017

Source(s)

eCQI CMS124