| Measure Information | 2022 Performance Period |
|---|---|
| CMS eCQM ID | CMS124v10 |
| 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 who are in hospice care for any part of the measurement period. Exclude patients receiving palliative care during the measurement period. |
| 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 |
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. |
| Telehealth Eligible | Yes |
| Next Version | |
| Previous Version |
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.
| 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 |
Data Element Repository
Header
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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
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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
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Updated the Denominator Exclusions to add an exclusion for palliative care.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
Logic
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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
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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
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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
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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
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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
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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
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Updated Hospice CQL Library to version 3.0.000.
Measure Section: Multiple Sections
Source of Change: Measure Lead
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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