Cervical Cancer Screening
Compare Versions of: "Cervical Cancer Screening"
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| Measure Information | 2022 Performance Period | 2023 Performance Period | 2024 Performance Period | 2025 Performance Period |
|---|---|---|---|---|
| Title | Cervical Cancer Screening | Cervical Cancer Screening | Cervical Cancer Screening | Cervical Cancer Screening |
| CMS eCQM ID | CMS124v10 | CMS124v11 | CMS124v12 | CMS124v13 |
| CBE ID* | Not Applicable | Not Applicable | Not Applicable | Not Applicable |
| MIPS Quality ID | 309 | 309 | 309 | 309 |
| Measure Steward | National Committee for Quality Assurance | National Committee for Quality Assurance | National Committee for Quality Assurance | National Committee for Quality Assurance |
| 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 |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process | Process | Process | Process |
| Stratification | *See CMS124v10.html | *See CMS124v11.html |
None |
None |
| Risk Adjustment | *See CMS124v10.html | *See CMS124v11.html |
None |
None |
| Rationale | *See CMS124v10.html | *See CMS124v11.html |
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). |
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 | *See CMS124v10.html | *See CMS124v11.html |
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)" |
The U.S Preventive Services Task Force (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) (USPSTF, 2018). 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) (USPSTF, 2018). The USPSTF recommends against screening for cervical cancer in women younger than 21 years. (D recommendation) (USPSTF, 2018). 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 (i.e., cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer (D recommendation) (USPSTF, 2018). |
| Improvement Notation |
Higher score equals better quality |
Higher score equals better quality |
Higher score equals better quality |
Higher score equals better quality |
| Definition | *See CMS124v10.html | *See CMS124v11.html |
None |
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. 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. |
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. |
| Initial Population |
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 |
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 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. |
Exclude patients who are in hospice 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 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 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 |
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 |
| Telehealth Eligible | Yes | Yes | Yes | Yes |
| Next Version | No Version Available | |||
| Previous Version | No Version Available |
Additional Resources for CMS124v10
Header
Updated the eCQM version number.
Measure Section: eCQM Version Number
Source of Change: Annual Update
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
Updated the rationale to align with current evidence.
Measure Section: Rationale
Source of Change: Measure Lead
Updated references.
Measure Section: Reference
Source of Change: Annual Update
Updated the guidance to clarify the measure intent and support implementation.
Measure Section: Guidance
Source of Change: Measure Lead
Replaced 'overlaps' or 'overlapping' in the denominator exclusions with plain language to clarify the measure intent.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
Updated the Denominator Exclusions to add an exclusion for palliative care.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
Logic
Added online assessments and telephone visits as appropriate encounters based on the increased use of telehealth services.
Measure Section: Initial Population
Source of Change: Measure Lead
Updated Denominator Exclusions definition and added PalliativeCare.Palliative Care in the Measurement Period definition to add an exclusion for palliative care.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
Added 'Congenital or Acquired Absence of Cervix' to the Absence of Cervix definition to support a comprehensive method of identifying hysterectomy with cervix removal.
Measure Section: Definitions
Source of Change: Measure Lead
Updated Denominator Exclusions definition and added PalliativeCare.Palliative Care in the Measurement Period definition to add an exclusion for palliative care.
Measure Section: Definitions
Source of Change: Measure Lead
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.
Measure Section: Multiple Sections
Source of Change: Standards Update
Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.
Measure Section: Multiple Sections
Source of Change: Standards Update
Updated Hospice CQL Library to version 3.0.000.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Added PalliativeCareExclusion CQL library version 1.0.000.
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 HPV Test (2.16.840.1.113883.3.464.1003.110.12.1059): Deleted 1 LOINC code (75406-9) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Hysterectomy with No Residual Cervix (2.16.840.1.113883.3.464.1003.198.12.1014): Deleted 3 ICD-9-CM codes (752.43, V88.01, V88.03) based on review by technical experts, SMEs, and/or public feedback. Deleted 2 ICD-10-CM codes (Z90.710, Z90.712) based on review by technical experts, SMEs, and/or public feedback. Added 3 CPT codes (56308, 57530, 57531) based on review by technical experts, SMEs, and/or public feedback. Added 2 SNOMED CT codes (447771005, 473171009) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Congenital or Acquired Absence of Cervix (2.16.840.1.113883.3.464.1003.111.12.1016) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Online Assessment (2.16.840.1.113883.3.464.1003.101.12.1089) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Palliative Care Encounter (2.16.840.1.113883.3.464.1003.101.12.1090) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Palliative Care Intervention (2.16.840.1.113883.3.464.1003.198.12.1135) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
Removed direct reference code SNOMED CT code (37687000) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added direct reference code LOINC code (71007-9) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead