Breast Cancer Screening

Last updated: May 3, 2018

CMS Measure ID: CMS125v4
Version: 4
NQF Number: None
Measure Description:

Percentage of women 40-69 years of age who had a mammogram to screen for breast cancer.

Initial Patient Population:

Women 41-69 years of age with a visit during the measurement period

Denominator Statement:

Equals Initial Population

Denominator Exclusions:

Women who had a bilateral mastectomy or for whom there is evidence of two unilateral mastectomies

Numerator Statement:

Women with one or more mammograms during the measurement period or the year prior to the measurement period

Numerator Exclusions:

Not Applicable

Denominator Exceptions:


Measure Steward: National Committee for Quality Assurance
Domain: Effective Clinical Care
Next Version:
Previous Version:
Measure Score: Proportion
Improvement Notation:

Higher score equals better quality.




Release Notes


  • Copyright updated.
  • Disclaimer updated.
  • eMeasure version number incremented.


  • Changed data type of 'result' or 'finding' to 'performed'.
  • Modified 'Diagnostic Study, Performed: Mammogram (result)' <=12 month(s) ends before end of Measurement Period' in numerator logic. Changed logic to read '< 24 months ends before end of Measurement Period' to properly capture all days within the measurement period and the year before the measurement period. Change based on standard duration calculation.
  • Removed result attribute from the mammogram data element.
  • Replaced 'ends before or during' (EBOD) with 'ends before end of' (EBE). As necessary, edited the associated number of (days, months, years) to maintain the same time period to accommodate the new timing operator.
  • Replaced 'ORs' with 'Union of' operator.
  • Replaced 'Patient Characteristic Birthdate' with 'Age at' operator.
  • The top level logical operator for the Numerator Exclusions, Denominator Exclusions, Denominator Exceptions, and Measure Population Exclusions defaults to 'OR'.

Value Sets

No changes

External Resources