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Cervical Cancer Screening

Last updated: May 3, 2018

CMS Measure ID: CMS124v6
Version: 6
NQF Number: 0032
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 every 3 years

* Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years

Initial Patient Population:

Women 23-64 years of age with a visit during the measurement period

Denominator Statement:

Equals Initial Populationinfo-icon

Denominator Exclusions:

Women who had a hysterectomy with no residual cervix.

Exclude patients who were in hospice care during the measurement year.

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 cytology/human papillomavirus (HPV) co-testing performed during the measurement period or the four years prior to the measurement period for women who are at least 30 years old at the time of the test

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: National Committee for Quality Assurance
Domain: Effective Clinical Care
Next Version:
Previous Version:
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 populationinfo-icon 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 QRDAinfo-icon-1. Patient self-report is not allowed for laboratory tests.

Include only cytology and HPV co-testing; in co-testing, both cytology and HPV tests are performed (i.e., the samples are collected and both tests are ordered, regardless of the cytology result) on the same date of service. Do not include reflex testing. In addition, if the medical record indicates the HPV test was performed only after determining the cytology result, this is considered reflex testing and does not meet criteria for the measure.

Notes: Value Set content updated Sept 2017

Specifications

Release Notes

Header

  • ​Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • ​Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​Updated Disclaimer.

    Measure Section: Disclaimer

    Source of Change: Measure Lead

  • ​​Updated Rationale.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated Guidance.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Added language to the Guidance to clarify how patient-reported information regarding procedures and diagnostic studies should be documented for calculation of the measure.

    Measure Section: Guidance

    Source of Change: JIRAinfo-icon (CQMinfo-icon-1739)

  • Added language to the Guidance to clarify that reflex testing does not meet the Numeratorinfo-icon criteria.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • ​Updated the exclusion statement in the header to exclude patients in hospice care from the Denominatorinfo-icon. Measures that focus on screenings and procedures may not be appropriate or a priority for those who are at end of life (ie, on hospice).

    Measure Section: Denominator Exclusionsinfo-icon

    Source of Change: Measure Lead

Logic

  • Added new lines of logic to the Denominator Exclusions for all NCQA-stewarded measures (except CMS82) to ensure patients in hospice care are excluded from the Denominator.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

Value Setinfo-icon

The VSACinfo-icon is the source of truth for the value set content, please visit the VSAC for downloads of current value setsinfo-icon.

  • Value set Hysterectomy with No Residual Cervix (2.16.840.1.113883.3.464.1003.198.12.1014): Added 2 SNOMEDCT codes (708877008, 708878003).

    Measure Section: QDMinfo-icon Data Elements

    Source of Change: Annual Update

  • Value set HPV Test (2.16.840.1.113883.3.464.1003.110.12.1059): Added 7 LOINC codes (59263-4, 59264-2, 69002-4, 71431-1, 77379-6, 77399-4, 77400-0).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Hospice care ambulatory (2.16.840.1.113762.1.4.1108.15): Added Hospice care ambulatory.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Encounter Inpatient (2.16.840.1.113883.3.666.5.307): Added Encounter Inpatient.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Discharged to Health Care Facility for Hospice Care (2.16.840.1.113883.3.117.1.7.1.207): Added Discharged to Health Care Facility for Hospice Care.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Discharged to Home for Hospice Care (2.16.840.1.113883.3.117.1.7.1.209): Added Discharged to Home for Hospice Care.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set HPV Test (2.16.840.1.113883.3.464.1003.110.12.1059): Deleted 1 LOINC code (49896-4).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

External Resources