CMS 124 - Cervical Cancer Screening

CMS124v5 (2017)

CMS124v6 (2018)

CMS124v7 (2019)

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 every 3 years
  • Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years

Initial Patient Population:  Women 23-64 years of age with a visit during the measurement period.

Denominator:  Equals Initial Population

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

Inverse Measure:  No

Clinical Instructions

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

Name Value Set
Encounter, Performed 2.16.840.1.113883.3.666.5.307
Encounter, Performed 2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed 2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed 2.16.840.1.113883.3.464.1003.101.12.1025
Encounter, Performed 2.16.840.1.113883.3.464.1003.101.12.1023
Intervention, Order 2.16.840.1.113762.1.4.1108.15
Intervention, Performed 2.16.840.1.113762.1.4.1108.15
Laboratory Test, Performed 2.16.840.1.113883.3.464.1003.110.12.1059
Laboratory Test, Performed 2.16.840.1.113883.3.464.1003.108.12.1017
Patient Characteristic Ethnicity 2.16.840.1.114222.4.11.837
Patient Characteristic Payer 2.16.840.1.114222.4.11.3591
Patient Characteristic Race 2.16.840.1.114222.4.11.836
Patient Characteristic Sex 2.16.840.1.113883.3.560.100.2
Patient Characteristic Sex 2.16.840.1.113762.1.4.1
Procedure, Performed 2.16.840.1.113883.3.464.1003.198.12.1014

Source(s)

Medical Codify

WebChart Documentation
Last Build: Wed, 08 Sep 2021 00:25:58 EDT Legacy Documentation