CMS 124 - Cervical Cancer Screening
Covered by this topic
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:
|
Initial Patient Population | Women 23-64 years of age with a visit during the measurement period |
Denominator | Equals Initial Population |
Denominator Exclusions |
|
Numerator | Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria:
|
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.
- Option 1: Document in the Past Procedures section
- Open the Past Procedures section
- 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).
- Add the Date and any relevant Notes.
- Click the Next button, or close the section
- Option 2: Document in the Preventive Care section
- Open the Preventive Care section
- 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
- Click the Next button, or close the section
- Option 3: Document in the Tests and Procedures section IF performing the screening in-house
- Open the Tests and Procedures section
- Using the autocomplete, begin typing the appropriate procedure name
- Click the Add to Exam button
- After adding the new section, open the procedure section and add any results or findings
- Click the Next button, or close the section
- Continue documenting the encounter, as needed
- When completed, Close and Archive the encounter
- Option 4: Scan/Index or Upload an accepted Document
- 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)
WebChart Documentation
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Mon, 09 Sep 2024 13:50:46 UTC
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