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 self-report for procedures as well as diagnostic studies should be recorded in 'Procedure, Performed' template or 'Diagnostic Study, Performed' template in QRDA-1.
Include only cytology and HPV "co-testing"; in co-testing, both cytology and HPV tests are performed (i.e., the samples are collected and both tests are ordered, regardless of the cytology result) on the same date of service. Do not include reflex testing. In addition, if the medical record indicates the HPV test was performed only after determining the cytology result, this is considered reflex testing and does not meet criteria for the measure.
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 whose hospice care overlaps 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 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 |
CMS124v8 |
124 |
2020 |
8.1.000 |
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 2018, an estimated 13,240 women were diagnosed with cervical cancer in the U.S., resulting in an estimated 4,170 deaths (Noone et al., 2018). If pre-cancerous lesions are detected early by Pap tests and treated, the likelihood of survival is nearly 100 percent (American Cancer Society, 2017).
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 |
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 |
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 |
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 |
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. (2017). Cancer prevention & early detection facts & figures, 2017-2018. Atlanta: Author.
Noone, A. M., Howlader, N., Krapcho, M., et al. (eds). (2018). SEER cancer statistics review, 1975-2015. Bethesda, MD: National Cancer Institute. Retrieved from https://seer.cancer.gov/csr/1975_2015/
U.S. Preventive Services Task Force. (2012). Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 156(12), 880-891.
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Source:
https://ecqi.healthit.gov/ecqm/measures/cms124v8