Breast Cancer Screening
Compare Versions of: "Breast Cancer Screening"
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Compare 2026 version to
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... Show more > |
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...Show more > |
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...Show more > |
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...Show more > |
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 |
Additional Resources for CMS125v14
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 |