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Breast Cancer Screening

Compare Versions of: "Breast Cancer Screening"

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.

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Measure Information 2023 Performance Period
Title Breast Cancer Screening
CMS eCQM ID CMS125v11
CBE ID* Not Applicable
MIPS Quality ID 112
Measure Steward National Committee for Quality Assurance
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

Measure Scoring Proportion measure
Measure Type Process
Stratification *See CMS125v11.html
Risk Adjustment *See CMS125v11.html
Rationale *See CMS125v11.html
Clinical Recommendation Statement *See CMS125v11.html
Improvement Notation

Higher score equals better quality

Definition *See CMS125v11.html
Guidance

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...

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Initial Population

Women 52-74 years of age by the end of the measurement period 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 by the end of the...

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Numerator

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

Denominator Exceptions

None

Telehealth Eligible Yes
Next Version
Previous Version No Version Available

Header

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Removed references to QRDA I guidance to avoid duplicating information provided in the CMS QRDA I Implementation Guide.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.

    Measure Section: Guidance

    Source of Change: Standards/Technical Update

  • Added age anchor specification to the initial population description to clarify measure requirements.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Revised the palliative care exclusion language to clarify the timing requirement.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Added detail to the frailty and advanced illness exclusion language to clarify the measure requirements.

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (JIRA): CQM-4971

  • Added age anchor specification to the denominator exclusion descriptions to clarify measure requirements.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Revised denominator exclusion narrative from living long term in an institution for more than 90 consecutive days language to living long term in a nursing home to reflect revised logic.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Added clarity to the numerator requirement by updating the mammogram lookback timeframe from during the 27 months prior to the end of the measurement period to any time on or between October 1 two years prior to the measurement period and the end of the measurement period to better align with measure intent.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Added a clinical recommendation statement to provide evidence that supports the inclusion of digital breast tomosynthesis (DBT) codes.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated grammar and punctuation to improve readability.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Combined AdultOutpatientEncounters.'Qualifying Encounters' and 'Telehealth Services' into a single definition to improve stylistic consistency across measures.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Replaced QDM datatype Encounter, Performed with Assessment, Performed and new modeling to improve data capturing of patients receiving long-term care.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Combined AdultOutpatientEncounters.'Qualifying Encounters' and 'Telehealth Services' into a single definition to improve stylistic consistency across measures.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated the timing precision of advanced illness encounter definitions by replacing the syntax '2 years or less on or before' with an interval.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated the timing precision in the definitions from datetime to date by adding 'day of', 'date from', and/or function 'ToDateInterval' to align with the measure intent.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Replaced the retired QDM datatype 'Device, Applied' with 'Assessment, Performed' for identifying frailty device usage.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Replaced QDM datatype 'Encounter, Performed' with 'Assessment, Performed' and new modeling to improve data capturing of patients receiving long-term care.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added QDM datatypes 'Encounter, Performed' and 'Assessment, Performed' and associated logic to the Hospice.'Has Hospice Services' definition to provide additional approaches for identifying patients receiving hospice services.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added QDM datatype 'Diagnosis' to provide an alternate approach for identifying patients receiving palliative care.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Revised the long-term care denominator exclusion logic to improve readability and clarity.

    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/Technical Update

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Updated the version number of the Adult Outpatient Encounters Library to v3.0.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated the version number of the Palliative Care Exclusion Library to v2.0.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated the version number of the Hospice Library to v4.0.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Added clarity to the numerator requirement by updating the mammogram lookback timeframe from during the 27 months prior to the end of the measurement period to any time on or between October 1 two years prior to the measurement period and the end of the measurement period to better align with measure intent.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Revised the initial population and denominator exclusions age anchor from the 'start of the measurement period' to the 'end of the measurement period' to align with the measure intent and CQL style best practices.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Updated the version number of the Advanced Illness and Frailty Exclusion ECQM Library to v7.0.000.

    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.

  • Added direct reference code LOINC code (98181-1) 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): Deleted 1 SNOMED CT code (459821000124104) 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 (71802-3) 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 (45755-6) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference code ICD-10-CM code (Z51.5) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Female (2.16.840.1.113883.3.560.100.2) with direct reference code AdministrativeGender code (F) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Outpatient (2.16.840.1.113883.3.464.1003.101.12.1087): Deleted 2 SNOMED CT codes (30346009, 37894004) based on validity of code during timing of look back period.

    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 1 SNOMED CT code (836435007) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 SNOMED CT code (12275171000119105) 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 108 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 122 SNOMED CT codes based on terminology update. Added 2 ICD-10-CM codes (C79.63, G35) 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 6 LOINC codes (91517-3, 91518-1, 91519-9, 91520-7, 91521-5, 91522-3) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Palliative Care Intervention (2.16.840.1.113883.3.464.1003.198.12.1135): Added 3 SNOMED CT codes (305686008, 305824005, 441874000) 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 3 RxNorm codes (1858970, 996572, 996624) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Removed value set Nursing Facility Visit (2.16.840.1.113883.3.464.1003.101.12.1012) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Removed value set Care Services in Long-Term Residential Facility (2.16.840.1.113883.3.464.1003.101.12.1014) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Hospice Encounter (2.16.840.1.113883.3.464.1003.1003) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Hospice Care Ambulatory (2.16.840.1.113762.1.4.1108.15) with value set Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference code SNOMED CT code (160734000) based on review by technical experts, SMEs, and/or public feedback.

    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 1 SNOMED CT code (836437004) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference code SNOMED CT code (373066001) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Sep 23, 2024