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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 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
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 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

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 priorExclude 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 priorExclude 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 priorExclude 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 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 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.

MIPS Quality ID 112 112 112
Telehealth Eligible Yes Yes Yes
Next Version No Version Available
Previous Version No Version Available
Notes

*For MVP use only

Header

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated grammar, wording, and/or formatting to improve readability and consistency.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Annual Update

  • Added language in the Guidance section to clarify the age requirement differences between the measure description and initial population.

    Measure Section: Guidance

    Source of Change: Test Case Review

  • Updated the denominator exclusion to include timing to provide clarity and to align with the logic.

    Measure Section: Denominator Exclusions

    Source of Change: Test Case Review

Logic

  • Updated the version number of the Advanced Illness and Frailty Exclusion eCQM Library to v8.0.000.

    Measure Section: Definitions

    Source of Change: Annual Update

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

    Measure Section: Definitions

    Source of Change: Annual Update

  • Updated the version number of the Palliative Care Exclusion ECQM Library to v3.0.000.

    Measure Section: Definitions

    Source of Change: Annual Update

  • Updated the version number of the Hospice Library to v5.0.000.

    Measure Section: Definitions

    Source of Change: Annual Update

  • Added 'day of' specificity to the palliative care expressions for consistency.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added QDM datatype 'Diagnosis' to the Hospice.'Has Hospice Services' definition referencing a new value set containing SNOMED finding codes to provide an additional approach for identifying patients receiving hospice care.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added 'day of' specificity to hospice expressions for consistency.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Replaced direct reference code 'Encounter with palliative care' with 'Palliative Care Diagnosis' value set in the PalliativeCare.Has Palliative Care in the Measurement Period definition to organize capture of patients receiving palliative care, per standards expert input.

    Measure Section: Definitions

    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: Definitions

    Source of Change: Standards/Technical Update

  • Updated the version number of the Advanced Illness and Frailty Exclusion eCQM Library to v8.0.000.

    Measure Section: Functions

    Source of Change: Annual Update

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

    Measure Section: Functions

    Source of Change: Annual Update

  • Updated the version number of the Hospice Library to v5.0.000.

    Measure Section: Functions

    Source of Change: Annual Update

  • Updated the version number of the Palliative Care Exclusion ECQM Library to v3.0.000.

    Measure Section: Functions

    Source of Change: Annual Update

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 Acute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1083): Added 3 CPT codes (99236, 99234, 99235) based on review by technical experts, SMEs, and/or public feedback. Added 1 SNOMED CT code (2876009) 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 47 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set (2.16.840.1.113883.3.464.1003.101.12.1010): Renamed to Emergency Department Evaluation and Management Visit based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Frailty Diagnosis (2.16.840.1.113883.3.464.1003.113.12.1074): Added 1 ICD-10-CM code (L89.000) 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 4 ICD-10-CM codes (R26.0, R26.1, R41.81, R53.83) based on review by technical experts, SMEs, and/or public feedback. Deleted 17 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584): Deleted 3 SNOMED CT codes (170935008, 170936009, 305911006) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Hospice Diagnosis (2.16.840.1.113883.3.464.1003.1165) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Hospice Encounter (2.16.840.1.113883.3.464.1003.1003): Added 2 SNOMED CT codes (305911006, 385765002) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Online Assessments (2.16.840.1.113883.3.464.1003.101.12.1089): Added 4 CPT codes (98980, 98981, 99444, 99457) based on review by technical experts, SMEs, and/or public feedback. Added 3 HCPCS codes (G2250, G2251, G2252) 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): Added 2 SNOMED CT codes (30346009, 37894004) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced direct reference code ICD-10-CM code (Z51.5) with value set Palliative Care Diagnosis (2.16.840.1.113883.3.464.1003.1167) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Palliative Care Intervention (2.16.840.1.113883.3.464.1003.198.12.1135): Deleted 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 Payer (2.16.840.1.114222.4.11.3591): Added 5 SOP codes (1111, 1112, 142, 344, 141) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Feb 06, 2024