CMS 124 - Cervical Cancer Screening

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## Overview [CMS124v12](https://medicalcodify.com/eh/?f=layoutnouser&func=&module=&tabmodule=&name=RXDBmain&searchterm=cms124&showresult=CMS124v12&showresulttype=Measure) (2024) [CMS124v11](https://medicalcodify.com/eh/?f=layoutnouser&func=&module=&tabmodule=&name=RXDBmain&searchterm=cms124&showresult=CMS124v11&showresulttype=Measure) (2023) [CMS124v10](https://medicalcodify.com/eh/?f=layoutnouser&func=&module=&tabmodule=&name=RXDBmain&searchterm=cms124&showresult=CMS124v10&showresulttype=Measure) (2022) ### Identifiers
CMS eCQM ID NQF eCQM ID NQF MIPS Quality ID
CMS124v12 – – 309
*MIE only supports data collection and reporting using eCQM specifications ### Definitions
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
Initial Patient Population Women 24-64 years of age with a visit during the measurement period
Denominator Equals Initial Population
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.
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 24-64 years of age by the end of the measurement period
  • 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
Numerator Exclusions –
Denominator Exceptions –
### Additional Information
Measure Type Process measure
Measure Scoring Proportion measure
Granularity Patient
Improvement Notation Higher score indicates better quality
Domain Effective Clinical Care
## Clinical Instructions Ensure all women aged 24-64 are screened for cervical cancer on the following schedule. Beginning at age 21, women should be screened using a Pap Test at least once every 3 years. Alternatively, beginning at age 30, women can be screened using an HPV Test at least once every 5 years. Laboratory screening tests will be recorded as observations with results either manually entered or received from a laboratory interface. ### Numerator Compliance #### Workflow A 1. To document a known test and result while documenting the Visit encounter, open the Tests and Procedures section 2. Search for the appropriate screening test * For patients under 30, use a Pap Test (2.16.840.1.113883.3.464.1003.108.12.1017) * For patients 30+, use either a Pap Test or HPV Test (2.16.840.1.113883.3.464.1003.110.12.1059) 3. Click Add to Exam 4. Open the newly added test section and record the test result 5. Complete the test and close the section 6. Continue documenting the encounter, as appropriate 7. When completed, Close and Archive the encounter #### Workflow B 1. To order a future test while documenting the Visit encounter, open the Visit Orders section 2. Search for the appropriate screening test * For patients under 30, use a Pap Test (2.16.840.1.113883.3.464.1003.108.12.1017) * For patients 30+, use either a Pap Test or HPV Test (2.16.840.1.113883.3.464.1003.110.12.1059) 3. Click Add 4. Close the Visit Orders section 5. Continue documenting the encounter, as appropriate 6. When completed, Close and Archive the encounter 7. The order added during the encounter MUST be resulted and completed with an appropriately coded observation in order to meet numerator compliance ### Denominator Exclusion Compliance #### Workflow A 1. While documenting the encounter, record an active diagnosis of Congenital or Acquired Absence of Cervix (2.16.840.1.113883.3.464.1003.111.12.1016) * Use the Smart Plan section quick lists to record the condition OR * Use the Past Medical History section quick lists to record the condition OR * Use the Symptoms/Diagnosis section quick lists to record the condition 2. Continue documenting the encounter, as appropriate 3. When completed, Close and Archive the encounter 4. This can also be documented outside of an encounter #### Workflow B 1. While documenting the encounter, record a procedure of Hysterectomy with No Residual Cervix (2.16.840.1.113883.3.464.1003.198.12.1014) * Use the Smart Plan section quick lists to record the procedure OR * Use the Past Procedures section quick lists to record the procedure 2. Continue documenting the encounter, as appropriate 3. When completed, Close and Archive the encounter 4. This can also be documented outside of an encounter #### Workflow C 1. Use the Long-Term, Chronic, and End of Life Care instructions to document one or more of the following a. Palliative Care b. Hospice Care ## Evidence ### Initial Patient Population
Name Value Set
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: 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
### Denominator Exclusions
Name Value Set
Assessment, Performed: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal) LOINC Code 71007-9
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: Palliative Care Encounter 2.16.840.1.113883.3.464.1003.101.12.1090
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
Procedure, Performed: Hysterectomy with No Residual Cervix 2.16.840.1.113883.3.464.1003.198.12.1014
### Numerator
Name Value Set
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
## Source(s) [eCQI CMS124](https://ecqi.healthit.gov/ecqm/ep/2024/cms124v12) ## Revision History
Date Description
09/05/2024 Updated for the 2024 reporting period
04/19/2022 Updated for the 2022 reporting period
06/18/2021 Updated for the 2021 reporting period
02/27/2020 Initial document creation

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Published: September 5, 2024