Back to top
Top
U.S. flag

An official website of the United States government

Dot gov

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

Https

Secure .gov websites use HTTPS
A lock ( ) or https:// means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.

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.

Compare version to

Measure Information 2022 Performance Period 2023 Performance Period 2024 Performance Period
Title Breast Cancer Screening Breast Cancer Screening Breast Cancer Screening
CMS eCQM ID CMS125v10 CMS125v11 CMS125v12
CBE ID Not Applicable Not Applicable Not Applicable
MIPS Quality ID 112 112 112
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

Definition *See CMS125v10.html *See CMS125v11.html

None

Initial Population

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

Women 52-74 years of age by the end of the measurement period with a visit during 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 any time on or between October 1 two years prior to the measurement period and 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

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 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.

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 on or before the end of the measurement period.

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.

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.

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.

This measure evaluates primary screening. Do not count biopsies, breast ultrasounds, or MRIs because they are not appropriate methods for primary breast cancer screening.

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.

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 Yes Yes
Rationale *See CMS125v10.html *See CMS125v11.html

Breast cancer is one of the most common types of cancers, accounting for 15 percent of all new cancer diagnoses in the U.S. (Noone et al., 2018). In 2015, over 3 million women were estimated to be living with breast cancer in the U.S. and it is estimated that 12 percent of women will be diagnosed with breast cancer at some point during their lifetime (Noone et al., 2018).

While there are other factors that affect a woman's risk of developing breast cancer, advancing age is a primary risk factor. Breast cancer is most frequently diagnosed among women ages 55-64; the median age at diagnosis is 62 years (Noone et al., 2018).

The chance of a woman being diagnosed with breast cancer in a given year increases with age. By age 40, the chances are 1 in 68; by age 50 it becomes 1 in 43; by age 60, it is 1 in 29 (American Cancer Society, 2017).

Stratification *See CMS125v10.html *See CMS125v11.html

None

Risk Adjustment *See CMS125v10.html *See CMS125v11.html

None

Clinical Recommendation Statement *See CMS125v10.html *See CMS125v11.html

The U.S. Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 50-74 years (B recommendation) (USPSTF, 2016).

The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years (C recommendation) (USPSTF, 2016).

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women aged 75 years or older (I statement) (USPSTF, 2016).

The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of digital breast tomosynthesis (DBT) as a primary screening method for breast cancer (I statement) (USPSTF, 2016).

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram (I statement) (USPSTF, 2016).

The National Comprehensive Cancer Network (NCCN) and the American College of Radiology (ACR) recommend using conventional mammography or DBT for screening women at low, intermediate or high risk for breast cancer (NCCN, 2021) (ACR, 2017).

Notes

*For MVP use only

Next Version No Version Available
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: Mar 04, 2024