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

Patient Group Definitions

Group	Description	Instructions Links
Initial Population	Women 24-64 years of age by the end of the measurement period 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 for any part of 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
CMS124v11	124	2023	11	N/A	42e7e489-790f-427a-a1a6-d6e807f65a6d

Steward	Developer	Endorsed By
National Committee for Quality Assurance	National Committee for Quality Assurance	None

Scoring Method	Measure Type	Stratification	Risk Adjustment
Proportion	Process	None	None

Rate Aggregation

None

Improvement Notation

Higher score indicates better quality

Rationale

Clinical Recommendation Statement

Definition

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	Hospice Encounter	2.16.840.1.113883.3.464.1003.1003
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	2.16.840.1.113883.3.526.3.1584
Intervention, Performed	Hospice Care Ambulatory	2.16.840.1.113883.3.526.3.1584
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	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