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Breast Cancer Screening

CMS Measure ID
CMS125v7
Version
7
NQF Number
2372
Measure Description

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

Initial Population

Women 51-74 years of age with a visit during the measurement period

Denominator Statement
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.

Exclude patients whose hospice care overlaps the measurement period.

Numerator Statement

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

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Previous Version
Next Version
Measure Scoring
Measure Type
Improvement Notation

Higher score equals better quality

Guidance

Patient self-report for procedures as well as diagnostic studies should be recorded in 'Procedure, Performed' template or 'Diagnostic Study, Performed' template in QRDA-1.

This measure evaluates primary screening. Do not count biopsies, breast ultrasounds, or MRIs because they are not appropriate methods for primary breast cancer screening.

Quality ID
112
Meaningful Measure

Specifications

Attachment Size
CMS125v7.html 56.27 KB
CMS125v7.zip 59.21 KB
CMS125v7_TRN.xlsx 20.1 KB

Release Notes

Header

  • Updated Version Number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated measure header rationale to align with most recent literature.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated clinical recommendation statement to align with current recommendations.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated header references to align with updated rationale and clinical recommendation statement.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated the measure guidance to remove irrelevant language and clarify where to locate information for the measure.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated the Denominator Exclusion statement for patients in hospice care to better align with the logic.

    Measure Section: Denominator Exclusions

    Source of Change: JIRA (CQM-2815)

Logic

  • Replaced 'Discharge status' attribute with 'Admission Source' and 'Discharge Disposition' attributes for 'Encounter, Performed' and 'Encounter, Active' datatypes to align with QDM 5.3 changes.

    Measure Section: Denominator Exclusions

    Source of Change: Standards Update

  • Added supplemental timing attributes to most datatypes in QDM 5.3 to facilitate accurate retrieval of time related information within CQL logic. Timing attributes now include a time interval, such as prevalence period or relevant period, and/or actual time of documentation with Author Datetime. Relevant period is the general method to describe start and stop times for datatypes. Prevalence period is used for some datatypes to more accurately define onset and abatement times.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Assigned cardinality to each attribute to be more explicit in guiding specification and implementation of QDM data elements. Cardinality refers to the number of instances of the attribute that can be included in the measure description. Cardinality for most attributes is 0.. 1 (i.e., can occur up to 1 time), but some attributes have a cardinality of 0.. * (i.e., can occur multiple times).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • CQL libraries contain sets of CQL definitions, or CQL expression statements. A context statement, patient or population, can now be used in a CQL library to clearly establish how the subsequent list of CQL expressions will be interpreted. A 'Population' context will interpret the CQL expression with reference to the entire population of the item being counted, patients or encounters. A 'Patient' context will interpret the CQL expression with reference to a single patient. Context statements are not required, but one or more context statements may be used within a library to help clarify how the CQL expressions will be interpreted. Patient context is the default if none is specified.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Removed the 'Face-To-Face Interaction' data element and added relevant SNOMED codes to the Encounter Grouping value sets to better align between the SNOMED and CPT encounter codes.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Replaced measure-defined definitions with similar definitions and functions from CQL shared libraries for consistency across measures.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated measure logic from Quality Data Model (QDM)-based logic to Clinical Quality Language (CQL)-based logic. Information on CQL can be found at the eCQI Resource center (https://ecqi.healthit.gov/cql). Information about specific versions of the new standards in use for CMS reporting periods can be found at the eCQI Resource Center (https://ecqi.healthit.gov/ecqm-tools-key-resources). Switching from QDM to CQL brings with it many changes, as well as enhanced expression capability, but only those changes with significant impact will be outlined in technical release notes. For example, in the case of timing operators, changes may only be summarized if those changes impact the measure calculation.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001): Added SNOMEDCT extensional value set (2.16.840.1.113883.3.464.1003.101.11.1264) including 7 codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Home Healthcare Services (2.16.840.1.113883.3.464.1003.101.12.1016): Added SNOMEDCT extensional value set (2.16.840.1.113883.3.464.1003.101.11.1265) including 11 codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Bilateral Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1005): Added 1 SNOMEDCT code (726636007).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Unilateral Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1020): Added 6 SNOMEDCT codes (726429001, 726430006, 726434002, 726435001, 726436000, 726437009).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Status Post Left Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1069): Added 1 SNOMEDCT code (137671000119105).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Status Post Right Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1070): Added 1 SNOMEDCT code (137681000119108).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set History of bilateral mastectomy (2.16.840.1.113883.3.464.1003.198.12.1068): Added 1 SNOMEDCT code (136071000119101).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 11 SOP codes (299, 32127, 32128, 391, 517, 524, 614, 621, 622, 623, 629) and deleted 3 SOP codes (63, 64, 69).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Face-to-Face Interaction (2.16.840.1.113883.3.464.1003.101.12.1048): Removed Face-to-Face Interaction.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Replaced SNOMEDCT single code value sets with direct referenced codes. A direct referenced code is a single concept code that is used to describe a clinical element directly within the logic. The use of direct referenced codes replaces the need for single code value sets. Measures using other code systems in single value sets may optionally transition to direct referenced codes.

    Measure Section: QDM Data Elements

    Source of Change: Standards Update

  • Value set Unilateral Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1020): Added 11 SNOMEDCT codes (12275171000119105, 12275221000119100, 237385002, 237388000, 303690008, 307995002, 33129002, 451201000124106, 451211000124109, 714111001, 714252004).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Payer (2.16.840.1.114222.4.11.3591): Deleted 1 SOP code (24).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Mammography (2.16.840.1.113883.3.464.1003.108.12.1018): Added 8 LOINC codes (72137-3, 72138-1, 72139-9, 72140-7, 72141-5, 72142-3, 86462-9, 86463-7).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

Last Updated: Oct 10, 2019