Breast Cancer Screening

Compare Versions of: "Breast Cancer Screening"

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Measure Information	2023 Performance Period	2024 Performance Period	2025 Performance Period	2026 Performance Period
Title	Breast Cancer Screening	Breast Cancer Screening	Breast Cancer Screening	Breast Cancer Screening
CMS eCQM ID	CMS125v11	CMS125v12	CMS125v13	CMS125v14
CBE ID*	Not Applicable	Not Applicable	Not Applicable	Not Applicable
MIPS Quality ID	112	112	112	112
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 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	Percentage of women 40-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period
Measure Scoring	Proportion measure	Proportion measure	Proportion measure	Proportion measure
Measure Type	Process	Process	Process	Process
Stratification	*See CMS125v11.html	None	None	Report a total rate, and each of the following age strata: Stratum 1: Patients age 42-51 by the end of the measurement period Stratum 2: Patients age 52-74 by the end of the measurement period
Risk Adjustment	*See CMS125v11.html	None	None	None
Rationale	*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). Show more > 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). Show less	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). Show more > 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). Show less	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). Show more > 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). Show less
Clinical Recommendation Statement	*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). Show more > 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). Show less	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). Show more > 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). Show less	The U.S. Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 40-74 years (B recommendation) (USPSTF, 2024). 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, 2024). 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, 2024). 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 and magnetic resonance imaging in women identified to have dense breasts on an otherwise negative screening mammogram (I statement) (USPSTF, 2024). 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). Show more > The U.S. Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 40-74 years (B recommendation) (USPSTF, 2024). 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, 2024). 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, 2024). 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 and magnetic resonance imaging in women identified to have dense breasts on an otherwise negative screening mammogram (I statement) (USPSTF, 2024). 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). Show less
Improvement Notation	Higher score equals better quality	Higher score equals better quality	Higher score equals better quality	Higher score equals better quality
Definition	*See CMS125v11.html	None	None	None
Guidance	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. Show more > 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. Show less	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. Show more > 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. Show less	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. Show more > 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. Show less	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. Show more > 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. Show less
Initial Population	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	Women 52-74 years of age by the end of the measurement period with a visit during the measurement period	Women 42-74 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	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 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. Show more > 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. Show less	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. Ex... clude 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. Show more > 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. Show less	Exclude patients who are in hospice 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. Ex... clude 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 diagnosis during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior 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 receiving palliative care for any part of the measurement period. Show more > Exclude patients who are in hospice 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 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 diagnosis during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior 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 receiving palliative care for any part of the measurement period. Show less	Exclude patients who are in hospice 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. Ex... clude 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 diagnosis during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior 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 receiving palliative care for any part of the measurement period. Show more > Exclude patients who are in hospice 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 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 diagnosis during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior 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 receiving palliative care for any part of the measurement period. Show less
Numerator	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	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	None
Denominator Exceptions	None	None	None	None
Telehealth Eligible	Yes	Yes	Yes	Yes
Next Version	CMS125v12	CMS125v13	CMS125v14	No Version Available
Previous Version	No Version Available	CMS125v11	CMS125v12	CMS125v13

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Specifications

Additional Resources for CMS125v14

CMS125-v14.0.000-TRN.xlsx

Header

TRN	Measure Section	Source of Change
Changed the 'eCQM Identifier (Measure Authoring Tool)' field name to 'CMS ID' based on tooling updates.	CMS ID	Standards/Technical Update
Updated the eCQM version number.	eCQM Version Number	Annual Update
Updated the generic measurement period from 'January 1, 20XX through December 31, 20XX' to specify 'January 1, 2026 through December 31, 2026' based on tooling updates.	Measurement Period	Standards/Technical Update
Updated the measure description age range from '50-74 years of age' to '40-74 years of age' to align with the updated USPSTF guidelines.	Description	Measure Lead
Updated copyright.	Copyright	Annual Update
Updated the stratification section to add information on total rate and two strata in measure that align with the updated USPSTF guidelines.	Stratification	Measure Lead
Updated clinical recommendation statement to reflect updated USPSTF mammogram screening guidelines.	Clinical Recommendation Statement	Measure Lead
Updated initial population age requirement from '52-74 years of age' to '42-74 years of age' to align with the updated USPSTF guidelines.	Initial Population	Measure Lead
Changed 'Numerator Exclusions' field to read 'None' instead of 'Not Applicable' when no exclusions are present.	Numerator Exclusions	Standards/Technical Update
Updated references and measure header to reflect current evidence and new or updated literature.	Multiple Sections	Measure Lead

Logic

TRN	Measure Section	Source of Change
Updated Measure Primary CQL Library Name from 'BreastCancerScreening' to 'CMS125BreastCancerScreening' for alignment with the CQL Style Guide.	Definitions	Standards/Technical Update
Updated the version number of the Global Common Functions Library to 9.0.000 and the library name from 'MATGlobalCommonFunctionsQDM' to 'CQMCommonQDM.'	Definitions	Annual Update
Updated the version number of the AdvancedIllnessandFrailtyQDM library to 10.0.000.	Definitions	Annual Update
Updated the version number of the HospiceQDM library to 7.0.000.	Definitions	Annual Update
Updated the version number of the PalliativeCareQDM library to 5.0.000.	Definitions	Annual Update
Replaced Direct Reference Code 'F' with SNOMEDCT Direct Reference code 'Female (finding)' (248152002) to represent 'Female' sex.	Definitions	Annual Update
Updated initial population age requirement and added age stratifications to align with the updated USPSTF guidelines.	Definitions	Measure Lead
Updated Measure Primary CQL Library Name from 'BreastCancerScreening' to 'CMS125BreastCancerScreening' for alignment with the CQL Style Guide.	Functions	Standards/Technical Update
Updated the version number of the Global Common Functions Library to 9.0.000 and the library name from 'MATGlobalCommonFunctionsQDM' to 'CQMCommonQDM.'	Functions	Annual Update
Updated the version number of the AdvancedIllnessandFrailtyQDM library to 10.0.000.	Functions	Annual Update
Updated the version number of the HospiceQDM library to 7.0.000.	Functions	Annual Update
Updated the version number of the PalliativeCareQDM library to 5.0.000.	Functions	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.

TRN	Measure Section	Source of Change
Replaced Direct Reference Code 'F' with SNOMEDCT Direct Reference code 'Female (finding)' (248152002) to represent 'Female' sex.	Terminology	Annual Update
Value Set 'Advanced Illness' (2.16.840.1.113883.3.464.1003.110.12.1082): Deleted 1 ICD10CM code (G20) based on review by technical experts, SMEs and/or public feedback. Added 356 SNOMEDCT codes (113901000052102, 1236931008, 1236940007, 1236941006, 1236942004, 1236943009, 1236944003, 1236945002, 1236947005, 1236948000, 1236953005, 1236954004, 1236955003, 1236956002, 1236957006, 1236958001, 1236960004, 1236961000, 1236962007, 1236963002, 1236964008, 1236966005, 1236967001, 1236968006, 1236969003, 1237031003, 1237032005, 1237033000, 1237034006, 1237035007, 1237036008, 1237037004, 1237038009, 1237039001, 1237041000, 1237042007, 1237043002, 1237044008, 1237045009, 1237046005, 1237047001, 1237048006, 1237050003, 1237051004, 1237052006, 1237053001, 1237055008, 1237056009, 1237057000, 1237372005, 1237414000, 1237415004, 1237416003, 1237422007, 1237423002, 1237424008, 1237425009, 1237426005, 1237427001, 1237428006, 1237454003, 1237455002, 1237456001, 1237457005, 1237458000, 1237460003, 1237461004, 1237465008, 1237466009, 1237467000, 1237469002, 1237471002, 1237472009, 1237473004, 1237474005, 1237476007, 1237477003, 1237478008, 1237479000, 1237480002, 1237481003, 1237482005, 1237483000, 1237484006, 1237485007, 1237487004, 1237488009, 1237489001, 1237490005, 1237492002, 1237493007, 1237494001, 1237495000, 1237496004, 1237497008, 1237498003, 1237516000, 1237517009, 1237518004, 1237519007, 1237520001, 1237521002, 1237522009, 1237523004, 1237524005, 1237525006, 1237526007, 1237527003, 1237528008, 1237529000, 1237530005, 1237531009, 1237621006, 1240346000, 1240351006, 1240352004, 1240353009, 1240355002, 1240359008, 1240362006, 1240363001, 1240370001, 1240372009, 1251445000, 1251454002, 1251456000, 1251457009, 1251458004, 1251459007, 1251460002, 1251465007, 1251466008, 1251467004, 1251468009, 1251469001, 1251470000, 1251471001, 1251472008, 1251473003, 1251474009, 1251475005, 1251482009, 1251483004, 1251484005, 1251485006, 1251486007, 1251487003, 1251489000, 1251490009, 1251491008, 1251492001, 1251493006, 1251494000, 1251495004, 1251496003, 1251497007, 1251498002, 1254689008, 1254691000, 1254723004, 1254724005, 1254725006, 1254726007, 1254727003, 1254728008, 1254732002, 1254733007, 1254734001, 1254735000, 1254740008, 1254745003, 1254746002, 1254747006, 1254748001, 1254749009, 1254750009, 1254752001, 1254753006, 1254755004, 1259465009, 1259467001, 1259469003, 1259471003, 1259473000, 1259476008, 1259478009, 1259480003, 1259485008, 1259488005, 1259492003, 1259494002, 1259496000, 1259499007, 1259501004, 1259503001, 1259511006, 1259513009, 1259517005, 1259519008, 1259522005, 1259524006, 1259529001, 1259531005, 1259579003, 1259581001, 1259584009, 1259586006, 1259591007, 1259656006, 1259661008, 1259663006, 1259665004, 1259667007, 1259675001, 1259677009, 1259679007, 1259990004, 1263484004, 1263555006, 1263585001, 1263601000, 1263639008, 1263640005, 1263641009, 1263642002, 1263643007, 1263651005, 1263652003, 1263653008, 1263654002, 1263655001, 1263656000, 1263657009, 1263658004, 1263659007, 1263660002, 1263786003, 1263911005, 1263912003, 1263913008, 1263914002, 1263999008, 1264003007, 1264066001, 1264067005, 1264068000, 1264115008, 1264116009, 1264117000, 1264118005, 1264258003, 1264357006, 1264358001, 1264364008, 1264367001, 1264369003, 1264495000, 1264497008, 1264499006, 1264500002, 1264501003, 1264502005, 1268352008, 1268353003, 1268354009, 1268386004, 1268388003, 1268390002, 1268392005, 1268393000, 1268394006, 1268395007, 1268532006, 1268542008, 1268546006, 1268561007, 1268563005, 1268698000, 1268702001, 1268716006, 1268888008, 1268911008, 1268957005, 1268961004, 1268966009, 1269042005, 1269047004, 1269048009, 1269051002, 1269052009, 1269121005, 1269122003, 1269123008, 1269125001, 1269126000, 1279841001, 1279882001, 1286863002, 1286896000, 1286898004, 1287657002, 1287665004, 1290060007, 1290066001, 1290080008, 1290115008, 1290116009, 1290117000, 1290690001, 1290695006, 1290697003, 1290698008, 1290700004, 1296659009, 1296851009, 1306321008, 1306322001, 1306323006, 1306543004, 1306544005, 1306545006, 1306546007, 1306547003, 1332483008, 1332484002, 1332485001, 1332486000, 1335987009, 1336170004, 1336171000, 1336172007, 1336173002, 1336176005, 1336177001, 1336182008, 1336185005, 1336186006, 1336188007, 1336190008, 1339031006, 1339049006, 1339050006, 1339051005, 14914851000119109, 14914931000119107, 15650751000119107, 253005002, 255039001, 683771000119101, 683781000119103, 683801000119104, 684891000119108, 686421000119103, 687341000119100, 717919005, 724003651000119103) based on review by technical experts, SMEs and/or public feedback. Deleted 160 SNOMEDCT codes (1217692004, 13351431000119102, 16260631000119101, 1661000119106, 1691000119104, 233765002, 269616004, 285598005, 285603002, 285604008, 285605009, 285606005, 285607001, 285608006, 285609003, 285610008, 285611007, 285612000, 285613005, 285614004, 285615003, 285616002, 285617006, 285618001, 285619009, 285631006, 285633009, 285634003, 285635002, 285637005, 285638000, 285639008, 285640005, 285641009, 285642002, 285643007, 285644001, 285645000, 314987003, 314988008, 314989000, 314990009, 314991008, 314992001, 314993006, 314994000, 314995004, 314996003, 314997007, 314998002, 314999005, 315000005, 315001009, 315002002, 315003007, 315004001, 315005000, 315006004, 315007008, 315008003, 315009006, 369455009, 369456005, 369457001, 369458006, 369459003, 369460008, 369461007, 369464004, 369467006, 369468001, 369476004, 369477008, 369478003, 369479006, 369480009, 369481008, 369482001, 369484000, 369486003, 369491002, 369492009, 369500009, 369501008, 369502001, 369538008, 369540003, 369542006, 369543001, 369544007, 369545008, 369546009, 369553000, 369554006, 369555007, 369556008, 369557004, 369558009, 369560006, 369561005, 369562003, 369563008, 369564002, 369565001, 369568004, 369569007, 369570008, 369571007, 369572000, 369573005, 369574004, 369575003, 369576002, 369577006, 369578001, 369581006, 369582004, 369583009, 369584003, 369585002, 369586001, 369588000, 369589008, 369590004, 369591000, 369592007, 369593002, 369602008, 369603003, 369604009, 369605005, 369606006, 369607002, 369608007, 369609004, 369610009, 422782004, 423987006, 424887002, 434431000124103, 705176003, 712849003, 733185001, 781076008, 87101000119106, 94176003, 94177007, 94182000, 94244003, 94276008, 94277004, 94297009, 94385006, 94387003, 94401004, 94443006, 94444000, 94653000, 94655007, 96981000119102) based on review by technical experts, SMEs and/or public feedback.	Terminology	Annual Update
Value Set 'Frailty Diagnosis' (2.16.840.1.113883.3.464.1003.113.12.1074): Deleted 1 SNOMEDCT code (52702003) based on review by technical experts, SMEs and/or public feedback.	Terminology	Annual Update
Value Set 'History of bilateral mastectomy' (2.16.840.1.113883.3.464.1003.198.12.1068): Deleted 1 SNOMEDCT code (16087411000119102) based on review by technical experts, SMEs and/or public feedback.	Terminology	Annual Update
Value Set 'Mammography' (2.16.840.1.113883.3.464.1003.108.12.1018): Added 5 LOINC codes (103894-2, 103885-0, 103893-4, 103892-6, 103886-8) based on review by technical experts, SMEs and/or public feedback. Deleted 10 LOINC codes (46342-2, 42174-3, 42168-5, 42169-3, 46355-4, 39154-0, 39152-4, 46354-7, 39150-8, 39153-2) based on review by technical experts, SMEs and/or public feedback.	Terminology	Annual Update
Value Set 'Office Visit' (2.16.840.1.113883.3.464.1003.101.12.1001): Added 1 SNOMEDCT code (185349003) based on review by technical experts, SMEs and/or public feedback.	Terminology	Annual Update
Replaced Value Set 'ONC Administrative Sex' (2.16.840.1.113762.1.4.1) with Value Set 'Federal Administrative Sex' (2.16.840.1.113762.1.4.1021.121) to represent Supplemental Data Element 'SDE Sex' based on revised standards.	Terminology	Standards/Technical Update
Value Set 'Palliative Care Encounter' (2.16.840.1.113883.3.464.1003.101.12.1090): Deleted 1 HCPCS code (M1017) based on review by technical experts, SMEs and/or public feedback.	Terminology	Annual Update
Value Set 'Telephone Visits' (2.16.840.1.113883.3.464.1003.101.12.1080): Added 8 CPT codes (98009, 98013, 98010, 98011, 98014, 98008, 98015, 98012) based on review by technical experts, SMEs and/or public feedback.	Terminology	Annual Update

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