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Breast Cancer Screening

Measure Information 2022 Performance Period
CMS eCQM ID CMS125v10
NQF Number 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

Initial Population

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

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 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.

Numerator

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

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Measure Steward National Committee for Quality Assurance
Quality Domain Effective Clinical Care
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 (https://ecqi.healthit.gov/qdm) for more information on the QDM.

MIPS Quality ID 112
Meaningful Measure Preventive Care
Telehealth Eligible Yes
Next Version
Previous Version

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Measure Information 2021 Performance Period 2022 Performance Period 2023 Performance Period
Title Breast Cancer Screening Breast Cancer Screening Breast Cancer Screening
CMS eCQM ID CMS125v9 CMS125v10 CMS125v11
NQF Number 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

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

Denominator

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.
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

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 Process measure
Improvement Notation

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 (https://ecqi.healthit.gov/qdm) 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.

MIPS Quality ID 112 112 112
Meaningful Measure Preventive Care Preventive Care Preventive Care
Telehealth Eligible Yes Yes Yes
Next Version CMS125v10 CMS125v11 No Version Available
Previous Version No Version Available

Release Notes

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 clinical recommendation statement to align with current clinical recommendations.

    Measure Section: Clinical Recommendation Statement

    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

  • Revised the advanced illness and frailty denominator exclusion to clarify the intent of the exclusion criteria.

    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

  • Revised the advanced illness and frailty denominator exclusion to align with the header and adhere to QDMv5.5 standards.​

    Measure Section: Denominator Exclusions

    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

  • Revised the advanced illness and frailty denominator exclusion to align with the header and adhere to QDMv5.5 standards.​

    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 names of Clinical Quality Language (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 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

  • Update Adult Outpatient Encounters CQL library to 2.0.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated Advanced Illness and Frailty Exclusions CQL Library to version 6.0.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated Hospice CQL Library to version 3.0.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Added PalliativeCareExclusion 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 Bilateral Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1005): Added 2 SNOMED CT codes (836436008, 870629001) based on review by technical experts, SMEs, and/or public feedback. Deleted 3 SNOMED CT codes (136071000119101, 428529004, 59860000) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Advanced Illness (2.16.840.1.113883.3.464.1003.110.12.1082): Added 34 ICD-10-CM codes based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations or terminology updates. Added 179 SNOMED CT codes based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations, and based on terminology updates.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Outpatient (2.16.840.1.113883.3.464.1003.101.12.1087): Added 11 SNOMED CT codes (185463005, 185464004, 185465003, 281036007, 30346009, 37894004, 3391000175108, 439740005, 77406008, 444971000124105, 84251009) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Frailty Device (2.16.840.1.113883.3.464.1003.118.12.1300): Added 124 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 22 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Frailty Encounter (2.16.840.1.113883.3.464.1003.101.12.1088): Deleted 1 SNOMED CT code (413467001) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Frailty Symptom (2.16.840.1.113883.3.464.1003.113.12.1075): Added 13 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 69 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Frailty Diagnosis (2.16.840.1.113883.3.464.1003.113.12.1074): Added 14 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 13 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Added 166 ICD-10-CM codes based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Dementia Medications (2.16.840.1.113883.3.464.1003.196.12.1510): Added 4 RxNorm codes (1599803, 1599805, 1805420, 1805425) based on change in measure requirements/measure specification. Deleted 3 RxNorm codes (1858970, 996572, 996624) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Unilateral Mastectomy Left (2.16.840.1.113883.3.464.1003.198.12.1133): Added 2 SNOMED CT codes (741009001, 741018004) based on review by technical experts, SMEs, and/or public feedback. Deleted 3 SNOMED CT codes (12275221000119100, 137671000119105, 429009003) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Unilateral Mastectomy Right (2.16.840.1.113883.3.464.1003.198.12.1134): Added 2 SNOMED CT codes (741010006, 741019007) based on review by technical experts, SMEs, and/or public feedback. Deleted 2 SNOMED CT codes (137681000119108, 429242008) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Mammography (2.16.840.1.113883.3.464.1003.108.12.1018): Added 18 LOINC codes based on terminology update. Deleted 3 HCPCS codes (G0202, G0204, G0206) based on validity of code during timing of look back period.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Acute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1083): Added 10 SNOMED CT codes (10378005, 18083007, 183452005, 19951005, 2252009, 73607007, 305339001, 50699000, 74857009, 78680009) based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations.

    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

  • Replaced value set ED (2.16.840.1.113883.3.464.1003.101.12.1085) with value set Emergency Department Visit (2.16.840.1.113883.3.464.1003.101.12.1010) 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

Last Updated: Aug 29, 2022