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Cervical Cancer Screening

Measure Information 2021 Performance Period
CMS Measure ID CMS124v9
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 within the last 3 years

* Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 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 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

Measure Steward National Committee for Quality Assurance
Quality Domain Effective Clinical Care
Measure Scoring Proportion measure
MIPS Quality ID 309
Meaningful Measure Preventive Care
Telehealth Eligible Yes
Next Version
Previous Version No Version Available

Compare eCQM Versions

The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.

Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.

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Measure Information 2021 Performance Period 2022 Performance Period 2023 Performance Period
CMS Measure ID CMS124v9 CMS124v10 CMS124v11
NQF Number Not Applicable Not Applicable 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 within the last 3 years

* Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years

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

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

Initial Population

Women 23-64 years of age with a visit during the measurement period

Women 23-64 years of age with a visit during the measurement period

Women 24-64 years of age by the end of the measurement period with a visit during the measurement period

Denominator Statement

Equals Initial Population

Equals Initial Population

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. 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 during the measurement period. 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 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 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

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 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

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 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

Not Applicable

Not Applicable

Denominator Exceptions

None

None

None

Measure Steward National Committee for Quality Assurance National Committee for Quality Assurance National Committee for Quality Assurance
Quality Domain Effective Clinical Care Effective Clinical Care Effective Clinical Care
Measure Scoring Proportion measure Proportion measure Proportion measure
Measure Type Process measure Process measure
Improvement Notation

Higher score equals better quality

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.

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 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

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.

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 QDM page for more information on the QDM.

MIPS Quality ID 309 309 309
Meaningful Measure Preventive Care Preventive Care Preventive Care
Telehealth Eligible Yes Yes Yes
Next Version CMS124v10 CMS124v11 No Version Available
Previous Version No Version Available

Release Notes

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Updated description to remove cytology and co-testing for women age 30-64 and to replace 'every' for 'within the last' to align with updated clinical recommendations.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​Updated the rationale to remove outdated references and content and to update references.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated the clinical recommendations statement to remove outdated references and update with the most recent clinical recommendations.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Standards Update

  • Added text to identify the Quality Data Model (QDM) version used in the measure specification.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Added text to indicate whether the measure is patient-based or episode-based.

    Measure Section: Guidance

    Source of Change: Standards Update

  • ​Updated numerator to remove Pap test requirement and allow Human papillomavirus (HPV) testing alone every 5 years, to align with updated clinical recommendations.

    Measure Section: Numerator

    Source of Change: ONC Project Tracking System (Jira): CQM-3725

Logic

  • ​Updated numerator to remove Pap test requirement and allow Human papillomavirus (HPV) testing alone every 5 years, to align with updated clinical recommendations.

    Measure Section: Numerator

    Source of Change: ONC Project Tracking System (Jira): CQM-3725

  • Added a new definition for an 'Absence of Cervix' to account for a congenital absence of cervix.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated timing logic for the follow-up assessment to use 'in Interval' to simplify logic and promote harmonization between measures.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Clinical Quality Language (CQL) Library version update: Updated version number of the Hospice Library (Hospice-2.2.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated CQL expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

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

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000). Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

    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 Hysterectomy with No Residual Cervix (2.16.840.1.113883.3.464.1003.198.12.1014): Deleted 1 CPT code (56308) based on terminology updates. Deleted 9 ICD-10-PCS codes (0UT90ZZ, 0UT94ZL, 0UT94ZZ, 0UT97ZZ, 0UT98ZZ, 0UT97ZL, 0UT98ZL, 0UT9FZL, 0UT9FZZ) as these codes are not specific to the cervix. Added 2 ICD-10-CM codes (Z90.710, Z90.712) based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: May 04, 2022