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 within the last 3 years
* Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 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 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 (https://ecqi.healthit.gov/qdm) for more information on the QDM.
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 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 |
| 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 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 test | Webchart Instructions |
| Numerator Exclusions | Not Applicable | Webchart Instructions |
| Denominator Exceptions | None | |
Details
| 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
None
Improvement Notation
Higher score equals better quality
Rationale
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)"
Definition
None
Transmission Format
TBD
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 |
References
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: https://seer.cancer.gov/statfacts/html/cervix.html
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. https://doi.org/10.1001/jama.2018.10897
Disclaimer
The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.
Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Copyright
This Physician Performance Measure (Measure) and related data specifications are owned and were developed by the National Committee for Quality Assurance (NCQA). NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in the Measure. The Measure can be reproduced and distributed, without modification, for noncommercial purposes (e.g., use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. (C) 2012-2020 National Committee for Quality Assurance. All Rights Reserved.
Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third party codes contained in the specifications.
CPT(R) contained in the Measure specifications is copyright 2004-2020 American Medical Association. LOINC(R) copyright 2004-2020 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2020 International Health Terminology Standards Development Organisation. ICD-10 copyright 2020 World Health Organization. All Rights Reserved.
Source:
https://ecqi.healthit.gov/ecqm/measures/cmsv1