Breast Cancer Screening

Last updated: May 3, 2018

CMS Measure ID: CMS125v6
Version: 6
NQF Number: 2372
Measure Description:

Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer

Initial Patient Population:

Women 51-74 years of age with a visit during the measurement period

Denominator Statement:

Equals Initial Populationinfo-icon

Denominator Exclusions:

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.

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

Numerator Statement:

Women with one or more mammograms during the measurement period or the 15 months prior to the measurement period

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:

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.

This measure evaluates primary screening. Do not count biopsies, breast ultrasounds, MRIs or tomosynthesis (3D mammography), because they are not appropriate methods for primary breast cancer screening.

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 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: JIRA (CQMinfo-icon-1739)

  • ​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 Exclusions

    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

  • Renamed value setinfo-icon Right Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1070) to Status Post Right Mastectomy and renamed value set Left Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1069) to Status Post Left Mastectomy to better reflect the codes included in each value set.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Modified the name of the 'Mammogram' value set to 'Mammography' to align with the HEDIS parent measure.

    Measure Section: Numeratorinfo-icon

    Source of Change: Measure Lead

  • Replaced the 'starts before start of' and 'starts before end of' logical operator to address situations where time stamps are not attached to procedures, diagnosis, and immunizations. Wherever applicable, the operators have been changed to 'starts before or concurrent with start of' or 'starts before or concurrent with end of' respectively.

    Measure Section: Numerator

    Source of Change: JIRA (CQM-1936)

Value Set

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

  • Value set Mammogram (2.16.840.1.113883.3.464.1003.108.12.1018): Renamed Mammogram to Mammography.

    Measure Section: QDMinfo-icon Data Elements

    Source of Change: Annual Update

  • Value set Left Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1069): Renamed Left Mastectomy to Status Post Left Mastectomy.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Right Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1070): Renamed Right Mastectomy to Status Post Right Mastectomy.

    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 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

External Resources