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Cervical Cancer Screening

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eCQMs for 2020 Performance Period

CMS2v9
CMS22v8
CMS50v8
CMS56v8
CMS66v8
CMS68v9
CMS69v8
CMS74v9
CMS75v8
CMS90v9
CMS117v8
CMS122v8
CMS124v8
CMS125v8
CMS127v8
CMS128v8
CMS129v9
CMS130v8
CMS131v8
CMS133v8
CMS134v8
CMS135v8
CMS136v9
CMS137v8
CMS138v8
CMS139v8
CMS142v8
CMS143v8
CMS144v8
CMS145v8
CMS146v8
CMS147v9
CMS149v8
CMS153v8
CMS154v8
CMS155v8
CMS156v8
CMS157v8
CMS159v8
CMS161v8
CMS165v8
CMS177v8
CMS249v2
CMS347v3
CMS349v2
CMS645v3
CMS771v1

General eCQM Information

CMS Measure ID CMS124v8
NQF Number Not Applicable
Measure 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 Population Women 23-64 years of age with a visit during the measurement period
Denominator Statement

Equals Initial Population
Denominator Exclusions

Women who had a hysterectomy with no residual cervix or a congenital absence of cervix.

Exclude patients whose hospice care overlaps the measurement period.
Numerator Statement

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
Numerator Exclusions

Not Applicable
Denominator Exceptions

None
Measure Steward National Committee for Quality Assurance
Domain Effective Clinical Care
Measure Scoring Proportion measure
Measure Type Process measure
Improvement Notation

Higher score equals better quality
Guidance

To ensure the measure is only looking for a cervical cytology test only after a woman turns 21 years of age, the youngest age in the initial population is 23.

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.

Include only cytology and HPV "co-testing"; in co-testing, both cytology and HPV tests are performed (i.e., the samples are collected and both tests are ordered, regardless of the cytology result) on the same date of service. Do not include reflex testing. In addition, if the medical record indicates the HPV test was performed only after determining the cytology result, this is considered reflex testing and does not meet criteria for the measure.
Quality ID 309
Meaningful Measure Preventive Care
Telehealth Eligible Yes
Previous Version
CMS124v7
Specifications
Attachment Size
CMS124v8.html 52.12 KB
CMS124v8.zip 63.29 KB
CMS124v8-TRN.xlsx 21.83 KB

Data Element Repository

Release Notes

CMS124v8-TRN.xlsx

Header

  • Updated eCQM version number.

    Measure Section: eCQM Version number

    Source of Change: Measure Lead

  • Updated NQF number to 'Not Applicable.'

    Measure Section: NQF Number

    Source of Change: Standards Update

  • Updated endorsed by field to 'None.'

    Measure Section: Endorsed By

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated rationale.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated references to align with American Psychological Association (APA) style.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated parenthetical citations to align with American Psychological Association (APA) style.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Updated HPV test timing in definition 'Pap Test With HPV Co Test Within 5 Years': changed from 'HPVTest.relevantPeriod starts 1 day or less before or on day of start of PapTestOver30YearsOld.relevantPeriod' to 'HPVTest.relevantPeriod starts within 1 day of start of PapTestOver30YearsOld.relevantPeriod.'

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (JIRA): CQM-3423

  • Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with CQL Style Guide.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MAT) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Hospice Library (Hospice-2.0.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

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 Hysterectomy with No Residual Cervix (2.16.840.1.113883.3.464.1003.198.12.1014): Added 15 SNOMED CT codes and deleted 18 SNOMED CT codes. Added 1 CPT code (58575). Added ICD-9-CM extensional value set (2.16.840.1.113883.3.464.1003.198.11.1134) including 13 codes. Added ICD-10-PCS extensional value set (2.16.840.1.113883.3.464.1003.198.11.1135) including 13 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • ​Removed code system versions from direct reference codes. Please refer to Appendix A of the Electronic Clinical Quality Measure Logic and Implementation Guidance document for a list of code system versions used in the eCQM specifications for 2020 reporting/performance.

    Measure Section: Terminology

    Source of Change: Standards Update

  • Standardized purpose statement language in value sets across eCQMs. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Dec 18, 2020