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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


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


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 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 whose hospice care overlaps 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 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 testWebchart Instructions
Numerator ExclusionsNot ApplicableWebchart Instructions
Denominator ExceptionsNone


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


Improvement Notation

Higher score equals better quality


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)



Transmission Format


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


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
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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