Cervical Cancer Screening | eCQI Resource Center

Measure Information	2023 Performance Period
CMS Measure ID	CMS124v11
NQF Number	Not Applicable
Measure 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 24-64 years of age by the end of the measurement period with a visit during the measurement period
Denominator Statement	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 for any part of the measurement period.
Numerator Statement	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 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	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.
MIPS Quality ID	309
Meaningful Measure	Preventive Care
Telehealth Eligible	Yes
Next Version	No Version Available
Previous Version	CMS124v10

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Measure Information	2021 Performance Period	2022 Performance Period	2023 Performance Period
CMS Measure ID	CMS124v9	CMS124v10	CMS124v11
NQF Number	Not Applicable	Not Applicable	Not Applicable
Measure 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
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
Denominator Statement	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.
Numerator Statement	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
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
Improvement Notation		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 (https://ecqi.healthit.gov/qdm) 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.
MIPS Quality ID	309	309	309
Meaningful Measure	Preventive Care	Preventive Care	Preventive Care
Telehealth Eligible	Yes	Yes	Yes
Next Version	CMS124v10	CMS124v11	No Version Available
Previous Version	No Version Available	CMS124v9	CMS124v10

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Specifications

Attachment	Size
CMS124v11.html	68.51 KB
CMS124v11.zip	82.65 KB
CMS124v11-TRN.xlsx	21.77 KB

Value Sets

Value Sets to be used with CMS124v11

Release Notes

CMS124v11-TRN.xlsx

Header

Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
Updated references.
Measure Section: Reference
Source of Change: Measure Lead
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

Logic

Updated the timing precision in the definitions to align with the measure intent by replacing the syntax, such as '3 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
Expanded options for evaluating age at the time of the HPV test to improve flexibility for capturing data.
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
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 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 Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
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
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
Revised the initial population 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 number of the Hospice Library to v4.0.000.
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.

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
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
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 Hysterectomy with No Residual Cervix (2.16.840.1.113883.3.464.1003.198.12.1014): Deleted 1 SNOMED CT code (473171009) 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
Value set Congenital or Acquired Absence of Cervix (2.16.840.1.113883.3.464.1003.111.12.1016): Added 1 SNOMED CT code (473171009) 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
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 LOINC code (45755-6) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set HPV Test (2.16.840.1.113883.3.464.1003.110.12.1059): Added 1 LOINC code (95539-3) 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