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Cervical Cancer Screening

General eCQM Information

CMS Measure ID CMS124v10
NQF Number Not Applicable
Measure 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

Initial Population Women 23-64 years of age with a visit during the measurement period
Denominator Statement

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.

Numerator Statement

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

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Measure Steward National Committee for Quality Assurance
Domain Effective Clinical Care
Measure Scoring Proportion
Measure Type Process
Improvement Notation

Higher score equals better quality

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 (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Quality ID 309
Meaningful Measure Preventive Care
Telehealth Eligible Yes
Previous Version

Release Notes

Header

  • Updated the eCQM version number.

    Measure Section: eCQM Version Number

    Source of Change: Annual Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated the rationale to align with current evidence.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Annual Update

  • Updated the guidance to clarify the measure intent and support implementation.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Replaced 'overlaps' or 'overlapping' in the denominator exclusions with plain language to clarify the measure intent.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated the Denominator Exclusions to add an exclusion for palliative care.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

Logic

  • Added online assessments and telephone visits as appropriate encounters based on the increased use of telehealth services.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Updated Denominator Exclusions definition and added PalliativeCare.Palliative Care in the Measurement Period definition to add an exclusion for palliative care.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Added 'Congenital or Acquired Absence of Cervix' to the Absence of Cervix definition to support a comprehensive method of identifying hysterectomy with cervix removal.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated Denominator Exclusions definition and added PalliativeCare.Palliative Care in the Measurement Period definition to add an exclusion for palliative care.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated Hospice CQL Library to version 3.0.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Added PalliativeCareExclusion CQL library version 1.0.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

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 HPV Test (2.16.840.1.113883.3.464.1003.110.12.1059): Deleted 1 LOINC code (75406-9) 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 3 ICD-9-CM codes (752.43, V88.01, V88.03) based on review by technical experts, SMEs, and/or public feedback. Deleted 2 ICD-10-CM codes (Z90.710, Z90.712) based on review by technical experts, SMEs, and/or public feedback. Added 3 CPT codes (56308, 57530, 57531) based on review by technical experts, SMEs, and/or public feedback. Added 2 SNOMED CT codes (447771005, 473171009) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Congenital or Acquired Absence of Cervix (2.16.840.1.113883.3.464.1003.111.12.1016) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Online Assessment (2.16.840.1.113883.3.464.1003.101.12.1089) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Palliative Care Encounter (2.16.840.1.113883.3.464.1003.101.12.1090) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Palliative Care Intervention (2.16.840.1.113883.3.464.1003.198.12.1135) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Removed direct reference code SNOMED CT code (37687000) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference code LOINC code (71007-9) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jul 08, 2021