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Cervical Cancer Screening

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Measure Information 2023 Performance Period
CMS eCQM ID CMS124v11
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 24-64 years of age by the end of the measurement period 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 for any part of 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.

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.
Telehealth Eligible Yes
Next Version
CMS124v12
Previous Version
CMS124v10

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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
CMS124v9
CMS124v10
CMS124v11
Notes
Download XML
Download CSV
Specifications
Attachment Size
CMS124v11.html 68.51 KB
CMS124v11.zip 82.65 KB
CMS124v11-TRN.xlsx 21.77 KB

Data Element Repository

Value Sets
Value Sets to be used with CMS124v11
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

Last Updated: May 02, 2023