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Breast Cancer Screening

Measure Information 2021 Performance Period
CMS eCQM ID CMS125v9
NQF Number Not Applicable
MIPS Quality ID 112
Description

Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period

Initial Population

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

Numerator

Women with one or more mammograms during the 27 months prior to the end of the measurement period

Numerator Exclusions

Not Applicable

Denominator

Equals Initial Population

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.

Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period.

Exclude patients 66 and older with advanced illness and frailty because it is unlikely that patients will benefit from the services being measured.

Denominator Exceptions

None

Steward National Committee for Quality Assurance
Measure Scoring Proportion measure
Measure Type Process measure
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.

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.

Telehealth Eligible Yes
Next Version
Previous Version No Version Available

Compare eCQM Versions

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

Filter Measure By
Measure Information 2021 Performance Period 2022 Performance Period 2023 Performance Period 2024 Performance Period
Title Breast Cancer Screening Breast Cancer Screening Breast Cancer Screening Breast Cancer Screening
CMS eCQM ID CMS125v9 CMS125v10 CMS125v11 CMS125v12
NQF Number Not Applicable Not Applicable Not Applicable Not Applicable
Description

Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period

Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period

Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period

Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period

Initial Population

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

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

Women 52-74 years of age by the end of the measurement period with a visit during the measurement period

Women 52-74 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 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. Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period. Exclude patients 66 and older with advanced illness and frailty because it is unlikely that patients will benefit from the services being measured. 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 who are in hospice care for any part of the measurement period. Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period. Exclude patients 66 and older with an indication of frailty for any part of the measurement period who meet any of the following criteria: - Advanced illness with two outpatient encounters during the measurement period or the year prior - OR advanced illness with one inpatient encounter during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior Exclude patients receiving palliative care during the measurement period. 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 who are in hospice care for any part of the measurement period. Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period. Exclude patients 66 and older by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria: - Advanced illness with two outpatient encounters during the measurement period or the year prior - OR advanced illness with one inpatient encounter during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior Exclude patients receiving palliative care for any part of the measurement period. 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 on or before the end of the measurement period. Exclude patients who are in hospice care for any part of the measurement period. Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period. Exclude patients 66 and older by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria: - Advanced illness with two outpatient encounters during the measurement period or the year prior - OR advanced illness with one inpatient encounter during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior Exclude patients receiving palliative care for any part of the measurement period.
Numerator

Women with one or more mammograms during the 27 months prior to the end of the measurement period

Women with one or more mammograms during the 27 months prior to the end of the measurement period

Women with one or more mammograms any time on or between October 1 two years prior to the measurement period and the end of the measurement period

Women with one or more mammograms any time on or between October 1 two years prior to the measurement period and the end of the measurement period

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 Process measure
Improvement Notation

Higher score equals better quality

Higher score equals better quality

Higher score equals better quality

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.

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.

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.

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.

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

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.

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

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.

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 112 112 112 112
Telehealth Eligible Yes Yes Yes Yes
Next Version CMS125v10 CMS125v11 CMS125v12 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 copyright.

    Measure Section: Copyright

    Source of Change: Annual 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 denominator exclusions to add the word 'consecutive' to clarify that the Long-Term Illness (LTI) exclusion should be for 90 consecutive days.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

Logic

  • Removed: or ( Count('Unilateral Mastectomy Procedure')= 2 ) from the logic to allow women with one unilateral mastectomy to be excluded.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated denominator exclusion logic for frailty and clarified that the long-term illness exclusion should be for 90 'consecutive' days to reduce ambiguity.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated encounters to occur 'on or' before the end of the measurement period to improve clarity.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Clinical Quality Language (CQL) Library version update: Updated version number of the Adult_Outpatient_Encounters Library (Adult_Outpatient_Encounters-1.3.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • 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 CQL Library version number of the advanced illness and frailty exclusion library (AdvancedIllnessandFrailtyExclusionECQM-5.5.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • 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 Frailty Device (2.16.840.1.113883.3.464.1003.118.12.1300): Removed extensional value set Frailty Device (2.16.840.1.113883.3.464.1003.118.11.1114) with HCPCS codes from the grouping and added Frailty Device SNOMED (2.16.840.1.113883.3.464.1003.118.11.1220) with SNOMED CT codes to the grouping to align with recommended terminology.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Frailty Symptom (2.16.840.1.113883.3.464.1003.113.12.1075): Deleted 4 SNOMED CT codes (267031002, 272060000, 272062008, 314109004) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Nursing Facility Visit (2.16.840.1.113883.3.464.1003.101.12.1012): Added 3 CPT codes (99315, 99316, 99318) based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations, to capture additional nursing facility visit encounter types.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Mammography (2.16.840.1.113883.3.464.1003.108.12.1018): Deleted 1 LOINC code (38067-5) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Acute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1083): Deleted 1 SNOMED CT code (2876009) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Unilateral Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1020): Removed Unilateral Mastectomy to not allow women with one unilateral mastectomy to be excluded.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced Value set Right (2.16.840.1.113883.3.464.1003.122.12.1035) with direct reference code SNOMED CT Code Right (qualifier value) (24028007) based on terminology update and to align with best practices for replacing single code value sets with direct reference codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced Value set Left (2.16.840.1.113883.3.464.1003.122.12.1036) with direct reference code SNOMED CT Code Left (qualifier value) (7771000) based on terminology update and to align with best practices for replacing single code value sets with direct reference codes.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: Apr 24, 2023