CMS 125 - Breast Cancer Screening

CMS125v5 (2017)

CMS125v6 (2018)

CMS125v7 (2019)

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

Initial Patient Population:  Women 51-74 years of age with a visit during the measurement period.

Denominator:  Equals Initial Population

Numerator: Women with one or more mammograms during the measurement period or the 15 months prior to the measurement period.

Inverse Measure:  No

Clinical Instructions

Use the Past Procedures section of the encounter to record a previous mammogram, in order to track all 50-74 year-old women with one or more mammograms recorded (15 months prior to or during the measurement period). Otherwise, the procedure can be recorded in the Preventive Care section of the encounter, or a mammogram can be scanned and indexed, to record the screening was completed.

  • While documenting the Visit encounter, either record the previous procedure or the receipt of the mammogram, or scan and index the mammogram, as appropriate:
    • Option 1: Document in Past Procedures section
      • Open the Past Procedures section.
      • Using the Procedure autocomplete, begin typing the name of the diagnostic procedure (e.g., Mammogram) with the appropriate concept ID.
      • Add the Date and any relevant Notes.
      • Click the Next button, or close the section.
    • Option 2: Document in the Preventive Care section of Visit encounter
      • Open the Preventive Care section.
      • Provide the date of the last reported procedure in the Enter New Date field (e.g., 01-21-2018). This date is the Last Reported Date.
      • Click the Next button, or close the section. 
  • Continue documenting the encounter, as needed.
  • When completed, Close and Archive the encounter.
  • Option 3: Scan/Index or Upload a Mammogram document
    • Using WebScan, scan and index the MAMMO document type configured with the necessary LOIN-C (24606-6).

Evidence

Initial Patient Population

Name Value Set
Encounter, Performed: Annual Wellness Visit 2.16.840.1.113883.3.526.3.1240
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: 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

Denominator

Equals Initial Population

Numerator

Name Value Set
Diagnostic Study, Performed: Mammography 2.16.840.1.113883.3.464.1003.108.12.1018

Denominator Exclusion

Name Value Set
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
Diagnosis: History of bilateral mastectomy 2.16.840.1.113883.3.464.1003.198.12.1068
Diagnosis: Status Post Left Mastectomy 2.16.840.1.113883.3.464.1003.198.12.1069
Diagnosis: Status Post Right Mastectomy 2.16.840.1.113883.3.464.1003.198.12.1070
Diagnosis: Unilateral Mastectomy, Unspecified Laterality 2.16.840.1.113883.3.464.1003.198.12.1071
Procedure, Performed: Bilateral Mastectomy 2.16.840.1.113883.3.464.1003.198.12.1005
Procedure, Performed: Unilateral Mastectomy 2.16.840.1.113883.3.464.1003.198.12.1020

Source(s)

Medical Codify

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