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Cervical Cancer Screening

Last updated: May 9, 2019

CMS Measure ID: CMS124v8
Version: 8
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 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 or a congenital absence of cervix.

Exclude patients whose hospice care overlaps 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 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
Previous Version:
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 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 QRDA-1.

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.

Quality ID: 309
Meaningful Measure: Preventive Care

Specifications

Release Notes

Header

  • Updated eCQMinfo-icon version number.

    Measure Section: eCQM Version number

    Source of Change: Measure Lead

  • Updated NQFinfo-icon number to 'Not Applicable.'

    Measure Section: NQF Number

    Source of Change: Standards Update

  • Updated endorsed by field to 'None.'

    Measure Section: Endorsed By

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated rationale.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated references to align with American Psychological Association (APA) style.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated parenthetical citations to align with American Psychological Association (APA) style.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Updated HPV test timing in definition 'Pap Test With HPV Co Test Within 5 Years': changed from 'HPVTest.relevantPeriod starts 1 day or less before or on day of start of PapTestOver30YearsOld.relevantPeriod' to 'HPVTest.relevantPeriod starts within 1 day of start of PapTestOver30YearsOld.relevantPeriod.'

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (JIRA)info-icon: CQMinfo-icon-3423

  • Updated the names of Clinical Quality Language (CQL)info-icon definitions, functions, and/or aliases for clarification and to align with CQL Style Guideinfo-icon.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7info-icon Standard: Clinical Quality Language Specificationinfo-icon, Release 1 STUinfo-icon 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MATinfo-icon) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Hospice Library (Hospice-2.0.000).

    Measure Section: Multiple Sections

    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 15 SNOMED CT codes and deleted 18 SNOMED CT codes. Added 1 CPT code (58575). Added ICD-9-CM extensional value set (2.16.840.1.113883.3.464.1003.198.11.1134) including 13 codes. Added ICD-10-PCS extensional value set (2.16.840.1.113883.3.464.1003.198.11.1135) including 13 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • ​Removed code systeminfo-icon versions from direct reference codes. Please refer to Appendix A of the Electronic Clinical Quality Measureinfo-icon Logic and Implementation Guidance document for a list of code system versions used in the eCQM specificationsinfo-icon for 2020 reporting/performance.

    Measure Section: Terminology

    Source of Change: Standards Update

  • Standardized purpose statement language in value sets across eCQMsinfo-icon. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

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