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Breast Cancer Screening

Last updated: May 9, 2019

CMS Measure ID: CMS125v8
Version: 8
NQF Number: Not Applicable
Measure Description:

Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period

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 whose hospice care overlaps the measurement period.

Exclude patients 66 and older who are living long term in an institution for more than 90 days during the measurement period.

Exclude patients 66 and older with advanced illness and frailty because it is unlikely that patients will benefit from the services being measured.

Numerator Statement:

Women with one or more mammograms during the 27 months prior to the end of the measurement period

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:

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.

This measure evaluates primary screening. Do not count biopsies, breast ultrasounds, or MRIs because they are not appropriate methods for primary breast cancer screening.

Quality ID: 112
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 description statement to include the timing component of 27 months prior to the end of the measurement period to provide clarity.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated rationale.

    Measure Section: Rationale

    Source of Change: Measure Lead

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

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated denominator exclusionsinfo-icon statement with addition of patients with advanced illness and frailty because it is unlikely that patients will need the services being measured.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated denominator exclusions statement with addition of patients 66 years of age and older who are living in a long-term institutional setting, such as a nursing home, for more than 90 days in the measurement period to align with the HEDIS parent measure exclusion.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated numeratorinfo-icon statement to include 27 months prior to the end of the measurement period to provide clarity and align with the logic.

    Measure Section: Numerator

    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

  • Revised logic to include new exclusion for patients with advanced illness and frailty. The new logic excludes patients who are 80 or older, use of frailty devices, dementia medications and encounters with diagnosis of advance illness encompassing the measurement period or encounter.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Revised logic to include new exclusion for patients 66 years of age and older who are living in a long-term institutional setting, such as a nursing home, for more than 90 days in the measurement period to align with the HEDIS parent measure exclusion.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Revised logic to include definitions for right and left mastectomy procedure to ensure if a recent mastectomy could be captured with procedure codes.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • ​​Revised the alias from 'UnilateralMastectomyProcedure' to 'UnilateralMastectomy' in the 'Unilateral Mastectomy Procedure' definition to align with the Clinical Quality Language (CQL)info-icon style guide recommendations.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated the names of Clinical Quality Language (CQL) 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

  • Updated version number of the Adult_Outpatient_Encounters Library (Adult_Outpatient_Encounters-1.2.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Added new CQL library with advanced illness and frailty exclusion definitions (AdvancedIllnessandFrailtyExclusionECQM-4.0.000).

    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 Bilateral Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1005): Added SNOMED CT extensional value set (2.16.840.1.113883.3.464.1003.198.11.1005) including 3 codes. Added ICD-9-CM extensional value set (2.16.840.1.113883.3.464.1003.198.11.1139) including 4 codes. Added ICD-10-PCS extensional value set (2.16.840.1.113883.3.464.1003.198.11.1140) including 1 code.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Unilateral Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1020): Deleted 8 SNOMED CT codes (428571003, 429400009, 726429001, 726430006, 726434002, 726435001, 726436000, 726437009).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Annual Wellness Visit (2.16.840.1.113883.3.526.3.1240): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1772) including 2 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Acute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1083): Added Acute Inpatient.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Advanced Illness (2.16.840.1.113883.3.464.1003.110.12.1082): Added Advanced Illness.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Nonacute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1084): Added Nonacute Inpatient.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set ED (2.16.840.1.113883.3.464.1003.101.12.1085): Added ED.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Observation (2.16.840.1.113883.3.464.1003.101.12.1086): Added Observation.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Outpatient (2.16.840.1.113883.3.464.1003.101.12.1087): Added Outpatient.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Frailty Device (2.16.840.1.113883.3.464.1003.118.12.1300): Added Frailty Device.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Frailty Encounter (2.16.840.1.113883.3.464.1003.101.12.1088): Added Frailty Encounter.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Frailty Symptom (2.16.840.1.113883.3.464.1003.113.12.1075): Added Frailty Symptom.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Frailty Diagnosis (2.16.840.1.113883.3.464.1003.113.12.1074): Added Frailty Diagnosis.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Dementia Medications (2.16.840.1.113883.3.464.1003.196.12.1510): Added Dementia Medications.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Unilateral Mastectomy Left (2.16.840.1.113883.3.464.1003.198.12.1133): Added Unilateral Mastectomy Left.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Unilateral Mastectomy Right (2.16.840.1.113883.3.464.1003.198.12.1134): Added Unilateral Mastectomy Right.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Nursing Facility Visit (2.16.840.1.113883.3.464.1003.101.12.1012): Added Nursing Facility Visit.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Care Services in Long-Term Residential Facility (2.16.840.1.113883.3.464.1003.101.12.1014): Added Care Services in Long-Term Residential Facility.

    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

External Resources