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Measure: CMS124

Cervical Cancer Screening

Measure Versions

eMeasure Code Measure Year Full Version Number Title
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


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 within the last 3 years * Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years


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 self-report for procedures as well as diagnostic studies should be recorded in 'Procedure, Performed' template or 'Diagnostic Study, Performed' template in QRDA-1. Evidence of hrHPV testing within the last 5 years also captures patients who had cotesting; therefore additional methods to identify cotesting are not necessary. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center ( for more information on the QDM.

Patient Group Definitions

Group Description Instructions Links
Initial PopulationWomen 23-64 years of age with a visit during the measurement periodWebchart Instructions
DenominatorEquals Initial PopulationWebchart Instructions
Denominator ExclusionsWomen who had a hysterectomy with no residual cervix or a congenital absence of cervix. Exclude patients who are in hospice care for any part of the measurement period. Exclude patients receiving palliative care during the measurement period.Webchart Instructions
NumeratorWomen 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 human papillomavirus (HPV) testing performed during the measurement period or the four years prior to the measurement period for women who are 30 years or older at the time of the testWebchart Instructions
Numerator ExclusionsNot ApplicableWebchart Instructions
Denominator ExceptionsNone


Full eMeasure Code eMeasure Identifier Measure Year Version NQF # GUID
CMS124v10 2022 10.0.000 Not Applicable 42e7e489-790f-427a-a1a6-d6e807f65a6d
Steward Developer Endorsed By
National Committee for Quality Assurance National Committee for Quality Assurance
Scoring Method Measure Type Stratification Risk Adjustment
Proportion PROCESS None None

Rate Aggregation


Improvement Notation

Higher score equals better quality


All women are at risk for cervical cancer. In 2020, an estimated 13,800 women were diagnosed with cervical cancer in the U.S., resulting in an estimated 4,290 deaths (National Cancer Institute, 2020). Screening can identify precancerous lesions and can detect invasive cancer early, when treatment is more likely to be successful (American Cancer Society, 2020).

Clinical Recommendation Statement

US Preventive Services Task Force (USPSTF) (2018) "The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting) (A recommendation)"

"The USPSTF recommends against screening for cervical cancer in women older than 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 younger than 21 years. (D recommendation)"

"The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and do not have a history of a high-grade precancerous lesion (ie, cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer. (D recommendation)"



Transmission Format


Applicable Value Sets

Category Value Set OID
Diagnosis Congenital or Acquired Absence of Cervix 2.16.840.1.113883.3.464.1003.111.12.1016
Encounter, Performed Encounter Inpatient 2.16.840.1.113883.3.666.5.307
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 Online Assessments 2.16.840.1.113883.3.464.1003.101.12.1089
Encounter, Performed Palliative Care Encounter 2.16.840.1.113883.3.464.1003.101.12.1090
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
Encounter, Performed Telephone Visits 2.16.840.1.113883.3.464.1003.101.12.1080
Intervention, Order Hospice care ambulatory 2.16.840.1.113762.1.4.1108.15
Intervention, Performed Hospice care ambulatory 2.16.840.1.113762.1.4.1108.15
Intervention, Performed Palliative Care Intervention 2.16.840.1.113883.3.464.1003.198.12.1135
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


CITATIONAmerican Cancer Society. (2020). Cancer Facts & Figures 2020. Atlanta: American Cancer Society.
CITATIONNational Cancer Institute. (2020). Cancer of the Cervix Uteri - Cancer Stat Facts. Accessed September 15, 2020:
CITATIONUS Preventive Services Task Force, Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., … Wong, J. B. (2018). Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statement. JAMA, 320(7), 674–686.


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