Measure: CMS125
Breast Cancer Screening
Measure Versions
| eMeasure Code | Measure Year | Full Version Number | Title |
|---|---|---|---|
| CMS125v12 | 2024 | 12.0.000 | Breast Cancer Screening |
| CMS125v11 | 2023 | 11 | Breast Cancer Screening |
| CMS125v10 | 2022 | 10.0.000 | Breast Cancer Screening |
| CMS125v9 | 2021 | 9.2.000 | Breast Cancer Screening |
| CMS125v8 | 2020 | 8.4.000 | Breast Cancer Screening |
| CMS125v7 | 2019 | 7.2.000 | Breast Cancer Screening |
| CMS125v6 | 2018 | 6.2.000 | Breast Cancer Screening |
| CMS125v5 | 2017 | 5.0.000 | Breast Cancer Screening |
Description
Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period.Guidance
Patient Group Definitions
| Group | Description | Instructions Links |
|---|---|---|
| Initial Population | Women 52-74 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 bilateral mastectomy or who have a history of a bilateral mastectomy or for whom there is evidence of a right and a left unilateral mastectomy. Exclude patients who are in hospice care for any part of the measurement period. Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period. Exclude patients 66 and older by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria: - Advanced illness with two outpatient encounters during the measurement period or the year prior - OR advanced illness with one inpatient encounter during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior Exclude patients receiving palliative care for any part of the measurement period. | Webchart Instructions |
| Numerator | Women with one or more mammograms any time on or between October 1 two years prior to the measurement period and the end of the measurement period | Webchart Instructions |
| Numerator Exclusions | Not Applicable | Webchart Instructions |
| Denominator Exceptions | None |
Details
| Full eMeasure Code | eMeasure Identifier | Measure Year | Version | NQF # | GUID |
|---|---|---|---|---|---|
| CMS125v11 | 125 | 2023 | 11 | 2372 | 19783c1b-4fd1-46c1-8a96-a2f192b97ee0 |
| 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 qualityRationale
Clinical Recommendation Statement
Definition
Transmission Format
Applicable Value Sets
| Category | Value Set | OID |
|---|---|---|
| Diagnosis | Frailty Diagnosis | 2.16.840.1.113883.3.464.1003.113.12.1074 |
| Diagnosis | History of bilateral mastectomy | 2.16.840.1.113883.3.464.1003.198.12.1068 |
| Diagnosis | Left Mastectomy | 2.16.840.1.113883.3.464.1003.198.12.1069 |
| Diagnosis | Right Mastectomy | 2.16.840.1.113883.3.464.1003.198.12.1070 |
| Diagnosis | Unilateral Mastectomy, Unspecified Laterality | 2.16.840.1.113883.3.464.1003.198.12.1071 |
| Diagnostic Study, Performed | Mammogram | 2.16.840.1.113883.3.464.1003.108.12.1018 |
| Encounter, Performed | Acute Inpatient | 2.16.840.1.113883.3.464.1003.101.12.1083 |
| Encounter, Performed | Annual Wellness Visit | 2.16.840.1.113883.3.526.3.1240 |
| Encounter, Performed | Emergency Department Visit | 2.16.840.1.113883.3.464.1003.101.12.1010 |
| Encounter, Performed | Encounter Inpatient | 2.16.840.1.113883.3.666.5.307 |
| Encounter, Performed | Frailty Encounter | 2.16.840.1.113883.3.464.1003.101.12.1088 |
| 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 | Nonacute Inpatient | 2.16.840.1.113883.3.464.1003.101.12.1084 |
| Encounter, Performed | Observation | 2.16.840.1.113883.3.464.1003.101.12.1086 |
| 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 | Outpatient | 2.16.840.1.113883.3.464.1003.101.12.1087 |
| 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 |
| Medication, Active | Dementia Medications | 2.16.840.1.113883.3.464.1003.196.12.1510 |
| 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 | Bilateral Mastectomy | 2.16.840.1.113883.3.464.1003.198.12.1005 |
| Procedure, Performed | Unilateral Mastectomy Left | 2.16.840.1.113883.3.464.1003.198.12.1133 |
| Procedure, Performed | Unilateral Mastectomy Right | 2.16.840.1.113883.3.464.1003.198.12.1134 |
| Symptom | Frailty Symptom | 2.16.840.1.113883.3.464.1003.113.12.1075 |