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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.

Compare 2026 version to

Table Options
Measure Information 2026 Performance Period
Title Breast Cancer Screening
CMS eCQM ID CMS125v14
CBE ID* Not Applicable
MIPS Quality ID 112
Measure Steward National Committee for Quality Assurance
Description

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
Measure Type Process
Stratification

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

None

Rationale

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...

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Clinical Recommendation Statement

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...

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Improvement Notation

Higher score equals better quality

Definition

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.

Please note the measure may include screenings performed outside the age range of patients referenced in the initial...

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Initial Population

Women 42-74 years of age by the end of the measurement period with a visit during the measurement period

Denominator

Equals Initial Population

Denominator Exclusions

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...

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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

Numerator Exclusions

None

Denominator Exceptions

None

Telehealth Eligible Yes
Next Version No Version Available
Previous Version

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

Last Updated: May 07, 2025