eCQM Title | # Cervical Cancer Screening
eCQM Identifier (Measure Authoring Tool) | 124 | eCQM Version Number | 12.0.000
NQF Number | Not Applicable | GUID | 42e7e489-790f-427a-a1a6-d6e807f65a6d
Measurement Period | January 1, 20XX through December 31, 20XX
Measure Steward | National Committee for Quality Assurance
Measure Developer | National Committee for Quality Assurance
Endorsed By | None
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 within the last 3 years
    - Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years
Copyright |
    This Physician Performance Measure (Measure) and related data specifications are owned and were developed by the National Committee for Quality Assurance (NCQA). NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in the Measure. The Measure can be reproduced and distributed, without modification, for noncommercial purposes (e.g., use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. (C) 2012-2022 National Committee for Quality Assurance. All Rights Reserved.

    Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third-party codes contained in the specifications.

    CPT(R) codes, descriptions and other data are copyright 2022. American Medical Association. All rights reserved. CPT is a trademark of the American Medical Association. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

    LOINC(R) copyright 2004-2022 Regenstrief Institute, Inc.

    This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation.

    ICD-10 copyright 2022 World Health Organization. All Rights Reserved.
Disclaimer |
    The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

    Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Measure Scoring | Proportion
Measure Type | Process
Stratification |
    None
Risk Adjustment |
    None
Rate Aggregation |
    None
Rationale |
    All women are at risk for cervical cancer. In 2020, an estimated 13,800 women were diagnosed with cervical cancer in the U.S., resulting in an estimated 4,290 deaths (National Cancer Institute, 2020). Screening can identify precancerous lesions and can detect invasive cancer early, when treatment is more likely to be successful (American Cancer Society, 2020).
Clinical Recommendation Statement |
    US Preventive Services Task Force (USPSTF) (2018) "The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting). (A recommendation)"

    "The USPSTF recommends against screening for cervical cancer in women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. (D recommendation)"

    "The USPSTF recommends against screening for cervical cancer in women younger than 21 years. (D recommendation)"

    "The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and do not have a history of a high-grade precancerous lesion (ie, cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer. (D recommendation)"
Improvement Notation |
    Higher score equals better quality
Reference |
    Reference Type: CITATION
    Reference Text: 'American Cancer Society. (2020). Cancer Facts & Figures 2020. Atlanta: American Cancer Society.'
Reference |
    Reference Type: CITATION
    Reference Text: 'National Cancer Institute. (2020). Cancer of the Cervix Uteri - Cancer Stat Facts. Retrieved September 15, 2020, from https://seer.cancer.gov/statfacts/html/cervix.html'
Reference |
    Reference Type: CITATION
    Reference Text: 'US Preventive Services Task Force, Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., … Wong, J. B. (2018). Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statement. JAMA, 320(7), 674–686. https://doi.org/10.1001/jama.2018.10897'
Definition |
    None
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.

    Please note the measure may include screenings performed outside the age range of patients referenced in the initial population. Screenings that occur prior to the measurement period are valid to meet measure criteria.

    Evidence of hrHPV testing within the last 5 years also captures patients who had cotesting; therefore additional methods to identify cotesting are not necessary.

    This eCQM is a patient-based measure.

    This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.
Transmission Format |
    TBD
Initial Population |
    Women 24-64 years of age by the end of the measurement period with a visit during the measurement period
Denominator |
    Equals Initial Population
Denominator Exclusions |
    Women who had a hysterectomy with no residual cervix or a congenital absence of cervix.

    Exclude patients who are in hospice care for any part of the measurement period.

    Exclude patients receiving palliative care for any part of the measurement period.
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 24-64 years of age by the end of the measurement period

    - Cervical human papillomavirus (HPV) testing performed during the measurement period or the four years prior to the measurement period for women who are 30 years or older at the time of the test
Numerator Exclusions |
    Not Applicable
Denominator Exceptions |
    None
Supplemental Data Elements |
    For every patient evaluated by this measure also identify payer, race, ethnicity and sex

## Table of Contents

- Population Criteria
- Definitions
- Functions
- Terminology
- Data Criteria (QDM Data Elements)
- Supplemental Data Elements
- Risk Adjustment Variables

### Population Criteria

- - Initial Population

    - -     AgeInYearsAt(date from
              end of "Measurement Period"
            )in Interval[24, 64]
              and exists ( ["Patient Characteristic Sex": "Female"] )
              and exists "Qualifying Encounters"

- - Denominator

    - -     "Initial Population"

- - Denominator Exclusions

    - -     Hospice."Has Hospice Services"
              or exists "Absence of Cervix"
              or PalliativeCare."Has Palliative Care in the Measurement Period"

- - Numerator

    - -     exists "Cervical Cytology Within 3 Years"
              or exists "HPV Test Within 5 Years for Women Age 30 and Older"

- - Numerator Exclusions

    - -     None

- - Denominator Exceptions

    - -     None

- - Stratification

    - -     None

### Definitions

- - Absence of Cervix

    - -     ( ["Procedure, Performed": "Hysterectomy with No Residual Cervix"] NoCervixProcedure
                where Global."NormalizeInterval" ( NoCervixProcedure.relevantDatetime, NoCervixProcedure.relevantPeriod ) ends on or before
                end of "Measurement Period"
            )
              union ( ["Diagnosis": "Congenital or Acquired Absence of Cervix"] NoCervixDiagnosis
                  where NoCervixDiagnosis.prevalencePeriod starts on or before
                  end of "Measurement Period"
              )

  - Cervical Cytology Within 3 Years

    - -     ["Laboratory Test, Performed": "Pap Test"] CervicalCytology
              where Global."LatestOf" ( CervicalCytology.relevantDatetime, CervicalCytology.relevantPeriod ) during day of Interval[start of "Measurement Period" - 2 years,
              end of "Measurement Period"]
                and CervicalCytology.result is not null

  - Denominator

    - -     "Initial Population"

  - Denominator Exclusions

    - -     Hospice."Has Hospice Services"
              or exists "Absence of Cervix"
              or PalliativeCare."Has Palliative Care in the Measurement Period"

  - Hospice.Has Hospice Services

    - -     exists ( ["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter
                where ( InpatientEncounter.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
                    or InpatientEncounter.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"
                )
                  and InpatientEncounter.relevantPeriod ends during day of "Measurement Period"
            )
              or exists ( ["Encounter, Performed": "Hospice Encounter"] HospiceEncounter
                  where HospiceEncounter.relevantPeriod overlaps day of "Measurement Period"
              )
              or exists ( ["Assessment, Performed": "Hospice care [Minimum Data Set]"] HospiceAssessment
                  where HospiceAssessment.result ~ "Yes (qualifier value)"
                    and Global."NormalizeInterval" ( HospiceAssessment.relevantDatetime, HospiceAssessment.relevantPeriod ) overlaps day of "Measurement Period"
              )
              or exists ( ["Intervention, Order": "Hospice Care Ambulatory"] HospiceOrder
                  where HospiceOrder.authorDatetime during day of "Measurement Period"
              )
              or exists ( ["Intervention, Performed": "Hospice Care Ambulatory"] HospicePerformed
                  where Global."NormalizeInterval" ( HospicePerformed.relevantDatetime, HospicePerformed.relevantPeriod ) overlaps day of "Measurement Period"
              )
            or exists ( ["Diagnosis": "Hospice Diagnosis"] HospiceCareDiagnosis
                  where HospiceCareDiagnosis.prevalencePeriod overlaps day of "Measurement Period"
              )

  - HPV Test Within 5 Years for Women Age 30 and Older

    - -     ["Laboratory Test, Performed": "HPV Test"] HPVTest
              where AgeInYearsAt(date from Global."LatestOf"(HPVTest.relevantDatetime, HPVTest.relevantPeriod))>= 30
                and Global."LatestOf" ( HPVTest.relevantDatetime, HPVTest.relevantPeriod ) during day of Interval[start of "Measurement Period" - 4 years,
                end of "Measurement Period"]
                and HPVTest.result is not null

  - Initial Population

    - -     AgeInYearsAt(date from
              end of "Measurement Period"
            )in Interval[24, 64]
              and exists ( ["Patient Characteristic Sex": "Female"] )
              and exists "Qualifying Encounters"

  - Numerator

    - -     exists "Cervical Cytology Within 3 Years"
              or exists "HPV Test Within 5 Years for Women Age 30 and Older"

  - PalliativeCare.Has Palliative Care in the Measurement Period

    - -     exists ( ["Assessment, Performed": "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)"] PalliativeAssessment
                where Global."NormalizeInterval" ( PalliativeAssessment.relevantDatetime, PalliativeAssessment.relevantPeriod ) overlaps day of "Measurement Period"
            )
              or exists ( ["Diagnosis": "Palliative Care Diagnosis"] PalliativeDiagnosis
                  where PalliativeDiagnosis.prevalencePeriod overlaps day of "Measurement Period"
              )
              or exists ( ["Encounter, Performed": "Palliative Care Encounter"] PalliativeEncounter
                  where PalliativeEncounter.relevantPeriod overlaps day of "Measurement Period"
              )
              or exists ( ["Intervention, Performed": "Palliative Care Intervention"] PalliativeIntervention
                  where Global."NormalizeInterval" ( PalliativeIntervention.relevantDatetime, PalliativeIntervention.relevantPeriod ) overlaps day of "Measurement Period"
              )

  - Qualifying Encounters

    - -     ( ["Encounter, Performed": "Office Visit"]
              union ["Encounter, Performed": "Preventive Care Services Established Office Visit, 18 and Up"]
              union ["Encounter, Performed": "Preventive Care Services Initial Office Visit, 18 and Up"]
              union ["Encounter, Performed": "Home Healthcare Services"]
              union ["Encounter, Performed": "Telephone Visits"]
              union ["Encounter, Performed": "Online Assessments"] ) ValidEncounters
              where ValidEncounters.relevantPeriod during day of "Measurement Period"

  - SDE Ethnicity

    - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

  - SDE Payer

    - -     ["Patient Characteristic Payer": "Payer"]

  - SDE Race

    - -     ["Patient Characteristic Race": "Race"]

  - SDE Sex

    - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

### Functions

- - Global.HasEnd(period Interval<DateTime>)

    - -     not (
              end of period is null
                or
                end of period = maximum DateTime
            )

  - Global.Latest(period Interval<DateTime>)

    - -     if ( HasEnd(period)) then
            end of period
              else start of period

  - Global.LatestOf(pointInTime DateTime, period Interval<DateTime>)

    - -     Latest(NormalizeInterval(pointInTime, period))

  - Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

    - -     if pointInTime is not null then Interval[pointInTime, pointInTime]
              else if period is not null then period
              else null as Interval<DateTime>

### Terminology

- code "Discharge to healthcare facility for hospice care (procedure)" ("SNOMEDCT Code (428371000124100)")
- code "Discharge to home for hospice care (procedure)" ("SNOMEDCT Code (428361000124107)")
- code "Female" ("AdministrativeGender Code (F)")
- code "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)" ("LOINC Code (71007-9)")
- code "Hospice care [Minimum Data Set]" ("LOINC Code (45755-6)")
- code "Yes (qualifier value)" ("SNOMEDCT Code (373066001)")
- valueset "Congenital or Acquired Absence of Cervix" (2.16.840.1.113883.3.464.1003.111.12.1016)
- valueset "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307)
- valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
- valueset "Home Healthcare Services" (2.16.840.1.113883.3.464.1003.101.12.1016)
- valueset "Hospice Care Ambulatory" (2.16.840.1.113883.3.526.3.1584)
- valueset "Hospice Diagnosis" (2.16.840.1.113883.3.464.1003.1165)
- valueset "Hospice Encounter" (2.16.840.1.113883.3.464.1003.1003)
- valueset "HPV Test" (2.16.840.1.113883.3.464.1003.110.12.1059)
- valueset "Hysterectomy with No Residual Cervix" (2.16.840.1.113883.3.464.1003.198.12.1014)
- valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001)
- valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
- valueset "Online Assessments" (2.16.840.1.113883.3.464.1003.101.12.1089)
- valueset "Palliative Care Diagnosis" (2.16.840.1.113883.3.464.1003.1167)
- valueset "Palliative Care Encounter" (2.16.840.1.113883.3.464.1003.101.12.1090)
- valueset "Palliative Care Intervention" (2.16.840.1.113883.3.464.1003.198.12.1135)
- valueset "Pap Test" (2.16.840.1.113883.3.464.1003.108.12.1017)
- valueset "Payer" (2.16.840.1.114222.4.11.3591)
- valueset "Preventive Care Services Established Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1025)
- valueset "Preventive Care Services Initial Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1023)
- valueset "Race" (2.16.840.1.114222.4.11.836)
- valueset "Telephone Visits" (2.16.840.1.113883.3.464.1003.101.12.1080)

### Data Criteria (QDM Data Elements)

- "Assessment, Performed: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)" using "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal) (LOINC Code 71007-9)"
- "Assessment, Performed: Hospice care [Minimum Data Set]" using "Hospice care [Minimum Data Set] (LOINC Code 45755-6)"
- "Diagnosis: Congenital or Acquired Absence of Cervix" using "Congenital or Acquired Absence of Cervix (2.16.840.1.113883.3.464.1003.111.12.1016)"
- "Diagnosis: Hospice Diagnosis" using "Hospice Diagnosis (2.16.840.1.113883.3.464.1003.1165)"
- "Diagnosis: Palliative Care Diagnosis" using "Palliative Care Diagnosis (2.16.840.1.113883.3.464.1003.1167)"
- "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient (2.16.840.1.113883.3.666.5.307)"
- "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services (2.16.840.1.113883.3.464.1003.101.12.1016)"
- "Encounter, Performed: Hospice Encounter" using "Hospice Encounter (2.16.840.1.113883.3.464.1003.1003)"
- "Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
- "Encounter, Performed: Online Assessments" using "Online Assessments (2.16.840.1.113883.3.464.1003.101.12.1089)"
- "Encounter, Performed: Palliative Care Encounter" using "Palliative Care Encounter (2.16.840.1.113883.3.464.1003.101.12.1090)"
- "Encounter, Performed: Preventive Care Services Established Office Visit, 18 and Up" using "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" using "Preventive Care Services Initial Office Visit, 18 and Up (2.16.840.1.113883.3.464.1003.101.12.1023)"
- "Encounter, Performed: Telephone Visits" using "Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080)"
- "Intervention, Order: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
- "Intervention, Performed: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
- "Intervention, Performed: Palliative Care Intervention" using "Palliative Care Intervention (2.16.840.1.113883.3.464.1003.198.12.1135)"
- "Laboratory Test, Performed: HPV Test" using "HPV Test (2.16.840.1.113883.3.464.1003.110.12.1059)"
- "Laboratory Test, Performed: Pap Test" using "Pap Test (2.16.840.1.113883.3.464.1003.108.12.1017)"
- "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
- "Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
- "Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
- "Patient Characteristic Sex: Female" using "Female (AdministrativeGender Code F)"
- "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"
- "Procedure, Performed: Hysterectomy with No Residual Cervix" using "Hysterectomy with No Residual Cervix (2.16.840.1.113883.3.464.1003.198.12.1014)"

### Supplemental Data Elements

- SDE Ethnicity

  - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

- SDE Payer

  - -     ["Patient Characteristic Payer": "Payer"]

- SDE Race

  - -     ["Patient Characteristic Race": "Race"]

- SDE Sex

  - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

### Risk Adjustment Variables

- None

Measure Set |
    None