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Cervical Cancer Screening

Compare Versions of: "Cervical 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 2025 Performance Period
Title Cervical Cancer Screening Cervical Cancer Screening Cervical Cancer Screening Cervical Cancer Screening
CMS eCQM ID CMS124v10 CMS124v11 CMS124v12 CMS124v13
CBE ID* Not Applicable Not Applicable Not Applicable Not Applicable
MIPS Quality ID 309 309 309 309
Measure Steward National Committee for Quality Assurance National Committee for Quality Assurance National Committee for Quality Assurance National Committee for Quality Assurance
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

Measure Scoring Proportion measure Proportion measure Proportion measure Proportion measure
Measure Type Process Process Process Process
Stratification *See CMS124v10.html *See CMS124v11.html

None

None

Risk Adjustment *See CMS124v10.html *See CMS124v11.html

None

None

Rationale *See CMS124v10.html *See CMS124v11.html

All women are at risk for cervical cancer. In 2020, an estimated 13,800 women were diagnosed with cervical cancer in the U.S., resulting in an estimated 4,290 deaths (National Cancer Institute, 2020). Screening can identify precancerous lesions and can detect invasive cancer early, when treatment is more likely to be successful (American Cancer Society, 2020).

All women are at risk for cervical cancer. In 2020, an estimated 13,800 women were diagnosed with cervical cancer in the U.S., resulting in an estimated 4,290 deaths (National Cancer Institute, 2020). Screening can identify precancerous lesions and can detect invasive cancer early, when treatment is more likely to be successful (American Cancer Society, 2020).

Clinical Recommendation Statement *See CMS124v10.html *See CMS124v11.html

US Preventive Services Task Force (USPSTF) (2018) "The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting). (A recommendation)"

"The USPSTF recommends against screening for cervical cancer in women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. (D recommendation)"

"The USPSTF recommends against screening for cervical cancer in women younger than 21 years. (D recommendation)"

"The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and do not have a history of a high-grade precancerous lesion (ie, cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer. (D recommendation)"

The U.S Preventive Services Task Force (USPSTF) recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting) (A recommendation) (USPSTF, 2018).

The USPSTF recommends against screening for cervical cancer in women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer (D recommendation) (USPSTF, 2018).

The USPSTF recommends against screening for cervical cancer in women younger than 21 years. (D recommendation) (USPSTF, 2018).

The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and do not have a history of a high-grade precancerous lesion (i.e., cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer (D recommendation) (USPSTF, 2018).

Improvement Notation

Higher score equals better quality

Higher score equals better quality

Higher score equals better quality

Higher score equals better quality

Definition *See CMS124v10.html *See CMS124v11.html

None

None

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.

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.

Initial Population

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

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 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.

Exclude patients who are in hospice 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 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 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

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

Telehealth Eligible Yes Yes Yes Yes
Next Version No Version Available
Previous Version No Version Available
Specifications
Attachment Size
CMS124v13.html 70.52 KB
CMS124v13.zip 84.45 KB
CMS124v13-TRN.xlsx 21.68 KB
eCQM Jira Issue Tracker
*Note there may be more tickets in the eCQM Tracker - ONC Project Tracking System (Jira) for this measure. Only tickets tagged with their associated CMS measure ID appear.

Header

  • Updated the eCQM version number.

    Measure Section:

    eCQM Version Number

    Source of Change:

    Annual Update

  • Changed all references from NQF to CBE to identify the consensus-based entity role.

    Measure Section:

    CBE Number

    Source of Change:

    Annual Update

  • Updated copyright.

    Measure Section:

    Copyright

    Source of Change:

    Annual Update

  • Aligned order of exclusions listed in the narrative and logic to improve overall measure specification readability.

    Measure Section:

    Denominator Exclusions

    Source of Change:

    Measure Lead

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

    Measure Section:

    Multiple Sections

    Source of Change:

    Annual Update

Logic

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'

    Measure Section:

    Definitions

    Source of Change:

    Annual Update

  • Updated the version number of the Hospice Library to v6.0.000 and the library name from 'Hospice' to 'HospiceQDM.'

    Measure Section:

    Definitions

    Source of Change:

    Annual Update

  • Updated the version number of the Palliative Care Exclusion Library to v4.0.000 and the library name from 'PalliativeCareExclusionECQM' to 'PalliativeCareQDM.'

    Measure Section:

    Definitions

    Source of Change:

    Annual Update

  • Renamed value set to 'Payer Type' to more accurately reflect the contents and intent of the value set.

    Measure Section:

    Definitions

    Source of Change:

    Standards/Technical Update

  • Updated the value set name for 'Online Assessments' to 'Virtual Encounter' for a more accurate description.

    Measure Section:

    Definitions

    Source of Change:

    Measure Lead

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'

    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.

  • Removed ICD-9 extensional value sets from select grouping value sets, leaving codes from active terminologies (ICD-10 and SNOMED), to reduce implementer burden.

    Measure Section:

    Terminology

    Source of Change:

    Standards/Technical Update

  • Value set Congenital or Acquired Absence of Cervix (2.16.840.1.113883.3.464.1003.111.12.1016): Deleted 4 ICD-9-CM codes (618.5, 752.43, V88.01, V88.03) based on applicability of value set and/or OID.

    Measure Section:

    Terminology

    Source of Change:

    Annual Update

  • Value set Home Healthcare Services (2.16.840.1.113883.3.464.1003.101.12.1016): Deleted 1 CPT code (99343) 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): Added 2 SNOMED CT codes (170935008, 170936009) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 SNOMED CT code (385765002) 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 10 ICD-9-CM codes (618.5, 68.41, 68.49, 68.51, 68.59, 68.61, 68.69, 68.71, 68.79, 68.8) based on applicability of value set and/or OID. Deleted 5 SNOMED CT codes (447771005, 27950001, 31545000, 59750000, 28301000) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Value set Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001): Deleted 2 SNOMED CT codes (30346009, 37894004) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 CPT code (99201) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Value set Virtual Encounter (2.16.840.1.113883.3.464.1003.101.12.1089): Deleted 2 CPT codes (98969, 99444) based on applicability of value set and/or OID. Deleted 3 HCPCS codes (G2061, G2062, G2063) based on applicability of value set and/or OID.

    Measure Section:

    Terminology

    Source of Change:

    Annual Update

  • Value set Palliative Care Encounter (2.16.840.1.113883.3.464.1003.101.12.1090): 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 (2.16.840.1.114222.4.11.3591): Renamed to Payer Type based on recommended value set naming conventions.

    Measure Section:

    Terminology

    Source of Change:

    Annual Update

  • Value set (2.16.840.1.113883.3.464.1003.101.12.1089): Renamed to Virtual Encounter based on recommended value set naming conventions.

    Measure Section:

    Terminology

    Source of Change:

    Annual Update

Last Updated: Jun 03, 2024