Measure: CMS124
Cervical Cancer Screening
Measure Versions
| eMeasure Code |
Measure Year |
Full Version Number |
Title |
| CMS124v12 |
2024 |
12.0.000 |
Cervical Cancer Screening |
| CMS124v11 |
2023 |
11 |
Cervical Cancer Screening |
| CMS124v10 |
2022 |
10.0.000 |
Cervical Cancer Screening |
| CMS124v9 |
2021 |
9.1.000 |
Cervical Cancer Screening |
| CMS124v8 |
2020 |
8.1.000 |
Cervical Cancer Screening |
| CMS124v7 |
2019 |
7.2.000 |
Cervical Cancer Screening |
| CMS124v6 |
2018 |
6.1.000 |
Cervical Cancer Screening |
| CMS124v5 |
2017 |
5.0.000 |
Cervical Cancer Screening |
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
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 population is 23
Patient Group Definitions
| Group |
Description |
Instructions Links |
| Initial Population | Women 23-64 years of age with a visit during the measurement period | Webchart Instructions |
| Denominator | Equals Initial Population | Webchart Instructions |
| Denominator Exclusions | Women who had a hysterectomy with no residual cervix | Webchart Instructions |
| Numerator | 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 | Webchart Instructions |
| Numerator Exclusions | Not Applicable | Webchart Instructions |
| Denominator Exceptions | None | |
Details
| Full eMeasure Code |
eMeasure Identifier |
Measure Year |
Version |
NQF # |
GUID |
| CMS124v5 |
124 |
2017 |
5.0.000 |
0032 |
42e7e489-790f-427a-a1a6-d6e807f65a6d |
| Steward |
Developer |
Endorsed By |
| National Committee for Quality Assurance |
National Committee for Quality Assurance |
National Quality Forum |
| Scoring Method |
Measure Type |
Stratification |
Risk Adjustment |
| Proportion |
PROCESS |
None |
None |
Rate Aggregation
None
Improvement Notation
Higher score equals better quality
Rationale
All women are at risk for cervical cancer, but it occurs most often in women over the age of 30. In 2015, approximately 12,900 women were diagnosed with cervical cancer in the U.S., resulting in an estimated 4,100 deaths (National Cancer Institute 2015). If pre-cancerous lesions are detected early by Pap tests and treated, the likelihood of survival is nearly 100 percent (American Cancer Society 2015). In 2013, women with no health insurance and recent immigrants were least likely to have a Pap test (American Cancer Society 2015).
Clinical Recommendation Statement
U.S. Preventive Services Task Force (USPSTF) (2012)
"The USPSTF recommends screening for cervical cancer in women aged 21 to 65 years with cytology (Papanicolaou smear) every 3 years or, for women aged 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and HPV testing every 5 years." (A recommendation)
"The USPSTF recommends against screening for cervical cancer in women younger than age 21 years." (D recommendation)
"The USPSTF recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer." (D recommendation)
"The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (cervical intraepithelial neoplasia grade 2 or 3) or cervical cancer." (D recommendation).
"The USPSTF recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years." (D recommendation)
Definition
None
Transmission Format
TBD
Applicable Value Sets
| Category |
Value Set |
OID |
| Encounter, Performed |
Face-to-Face Interaction |
2.16.840.1.113883.3.464.1003.101.12.1048 |
| Encounter, Performed |
Home Healthcare Services |
2.16.840.1.113883.3.464.1003.101.12.1016 |
| Encounter, Performed |
Office Visit |
2.16.840.1.113883.3.464.1003.101.12.1001 |
| Encounter, Performed |
Preventive Care Services - Established Office Visit, 18 and Up |
2.16.840.1.113883.3.464.1003.101.12.1025 |
| Encounter, Performed |
Preventive Care Services-Initial Office Visit, 18 and Up |
2.16.840.1.113883.3.464.1003.101.12.1023 |
| Laboratory Test, Performed |
HPV Test |
2.16.840.1.113883.3.464.1003.110.12.1059 |
| Laboratory Test, Performed |
Pap Test |
2.16.840.1.113883.3.464.1003.108.12.1017 |
| Patient Characteristic Ethnicity |
Ethnicity |
2.16.840.1.114222.4.11.837 |
| Patient Characteristic Payer |
Payer |
2.16.840.1.114222.4.11.3591 |
| Patient Characteristic Race |
Race |
2.16.840.1.114222.4.11.836 |
| Patient Characteristic Sex |
Female |
2.16.840.1.113883.3.560.100.2 |
| Patient Characteristic Sex |
ONC Administrative Sex |
2.16.840.1.113762.1.4.1 |
| Procedure, Performed |
Hysterectomy with No Residual Cervix |
2.16.840.1.113883.3.464.1003.198.12.1014 |
References
American Cancer Society. 2015. "Cancer Prevention & Early Detection Facts & Figures 2015-2016." Atlanta: American Cancer Society.
National Cancer Institute. 2015. "SEER Stat Fact Sheets: Cervix Uteri Cancer." Bethesda, MD. http://seer.cancer.gov/statfacts/html/cervix.html
U.S. Preventive Services Task Force. 2012. "Screening for Cervical Cancer: U.S. Preventive Services Task Force Recommendation Statement." Ann Intern Med. 156(12):880-91.
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Source:
https://ecqi.healthit.gov/ecqm/measures/cms124v5