Cervical Cancer Screening | eCQI Resource Center

Measure Information	2021 Performance Period
CMS eCQM ID	CMS124v9
NQF Number	Not Applicable
MIPS Quality ID	309
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
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 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	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.
Denominator Exceptions	None
Steward	National Committee for Quality Assurance
Measure Scoring	Proportion measure
Telehealth Eligible	Yes
Next Version	CMS124v10
Previous Version	No Version Available

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Measure Information	2021 Performance Period	2022 Performance Period	2023 Performance Period	2024 Performance Period
Title	Cervical Cancer Screening	Cervical Cancer Screening	Cervical Cancer Screening	Cervical Cancer Screening
CMS eCQM ID	CMS124v9	CMS124v10	CMS124v11	CMS124v12
NQF Number	Not Applicable	Not Applicable	Not Applicable	Not Applicable
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	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	Women 24-64 years of age by the end of the measurement period with a visit during the measurement period
Denominator	Equals Initial Population	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.	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 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	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	Not Applicable	Not Applicable	Not Applicable
Denominator Exceptions	None	None	None	None
Measure Steward	National Committee for Quality Assurance	National Committee for Quality Assurance	National Committee for Quality Assurance	National Committee for Quality Assurance
Measure Scoring	Proportion measure	Proportion measure	Proportion measure	Proportion measure
Measure Type		Process measure	Process measure	Process measure
Improvement Notation		Higher score equals better quality	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 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.	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 QDM page for more information on the QDM.
MIPS Quality ID	309	309	309	309
Telehealth Eligible	Yes	Yes	Yes	Yes
Next Version	CMS124v10	CMS124v11	CMS124v12	No Version Available
Previous Version	No Version Available	CMS124v9	CMS124v10	CMS124v11

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Data Element Repository

Data Elements contained within CMS124v9

Value Sets

Value Sets to be used with CMS124v9

Release Notes

CMS124v9-TRN.xlsx

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