Breast Cancer Screening | eCQI Resource Center

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
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.
MIPS Quality ID	112
Telehealth Eligible	Yes
Next Version	CMS125v11
Previous Version	CMS125v9

Compare eCQM Versions

The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.

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

Download

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
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 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
Telehealth Eligible	Yes	Yes	Yes
Next Version	CMS125v10	CMS125v11	No Version Available
Previous Version	No Version Available	CMS125v9	CMS125v10

Download XML

Download CSV

Specifications

Attachment	Size
CMS125v10.html	94.36 KB
CMS125v10.zip	114.14 KB
CMS125v10-TRN-v2.xlsx	20.75 KB

Data Element Repository

Data Elements contained within CMS125v10

Value Sets

Value Sets to be used with CMS125v10

Release Notes

CMS125v10-TRN-v2.xlsx

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