Breast Cancer Screening

Last updated: January 31, 2017

CMS Measure ID: CMS125v5
Version: 5
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 Population

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

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
Previous Version: Breast Cancer Screening
Improvement Notation:

Higher score equals better quality

Guidance:

None

Specifications

Release Notes

Header

  • ​Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • Added exclusion for women who self-report as previously having a mastectomy.

    Section: Denominator Exclusions

    Source: Measure Lead

  • Update the age range from 40-69 to 50-74 years of age to align with USPSTF guidelines.

    Section: Description

    Source: JIRA (CQM-1635)

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Annual Update

  • Added NQF as endorsing organization and endorsement number.

    Section: Endorsed By

    Source: JIRA (CQM-1635)

  • Update the age range from 40-69 to 50-74 years of age to align with USPSTF guidelines.

    Section: Initial Population

    Source: JIRA (CQM-1635)

  • Added NQF as endorsing organization and endorsement number.

    Section: NQF Number

    Source: JIRA (CQM-1635)

  • Extended numerator timeframe from 24 months to 27 months to allow a 3-month grace period.

    Section: Numerator

    Source: Measure Lead

Logic

  • Added exclusion for women who self-report as previously having a mastectomy.

    Section: Denominator Exclusions

    Source: Measure Lead

  • Replaced ‘laterality’ attribute with ‘anatomical location site’ attribute on ‘Procedure, performed’ and ‘Diagnosis’ datatypes to conform to QDM 4.2 changes.

    Section: Denominator Exclusions

    Source: QDM Standards

  • Update the age range from 40-69 to 50-74 years of age to align with USPSTF guidelines.

    Section: Initial Population

    Source: JIRA (CQM-1635)

  • Extend numerator timeframe from 24 months to 27 months to allow a 3-month grace period.

    Section: Numerator

    Source: Measure Lead

  • Replaced ‘laterality’ attribute with ‘anatomical location site’ attribute on ‘Procedure, performed’ and ‘Diagnosis’ datatypes to conform to QDM 4.2 changes.

    Section: QDM Data Elements

    Source: QDM Standards

  • Value set Female (2.16.840.1.113883.3.560.100.2): Changed code system from 'AdministrativeSex' to 'AdministrativeGender'.

    Section: QDM Data Elements

    Source: Code System Update

Value Set

  • Value set Bilateral Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1005): Added 1 SNOMEDCT code (456903003).

    Section: None

    Source: None

  • Value set History of bilateral mastectomy (2.16.840.1.113883.3.464.1003.198.12.1068): Added History of bilateral mastectomy.

    Section: None

    Source: None

  • Value set Left (2.16.840.1.113883.3.464.1003.122.12.1036): Added 1 SNOMEDCT code (419161000).

    Section: None

    Source: None

  • Value set Left Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1069): Added Left Mastectomy.

    Section: None

    Source: None

  • Value set Male (2.16.840.1.113883.3.560.100.1): Changed code system from 'AdministrativeSex' to 'AdministrativeGender'.

    Section: None

    Source: Code System Update

  • Value set Right (2.16.840.1.113883.3.464.1003.122.12.1035): Added 1 SNOMEDCT code (419465000).

    Section: None

    Source: None

  • Value set Right Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1070): Added Right Mastectomy.

    Section: None

    Source: None

  • Value set Unilateral Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1020): Deleted 6 SNOMEDCT codes (22964006, 317230007, 72269009, 73359007, 8115005, 88764002).

    Section: None

    Source: None

  • Value set Unilateral Mastectomy, Unspecified Laterality (2.16.840.1.113883.3.464.1003.198.12.1071): Added Unilateral Mastectomy, Unspecified Laterality.

    Section: None

    Source: None

External Resources