CMS 125 - Breast Cancer Screening

Overview

CMS125v8 (2020)
CMS125v9 (2021)
CMS125v10 (2022)

Identifiers

CMS eCQM IDNQF eCQM IDNQFMIPS Quality ID
CMS125v102372112
*MIE only supports data collection and reporting using eCQM specifications

Definitions

DescriptionPercentage 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
Initial Patient PopulationWomen 51-74 years of age with a visit during the measurement period
DenominatorEquals Initial Population
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 who are living long term in an institution for more than 90 consecutive days during the measurement period.

  • Exclude patients 66 and older with an indication of frailty for any part of the measurement period who meet any of the following criteria:

    • Advanced illness with two outpatient encounters during the measurement period or the year prior

    • Advanced illness with one inpatient encounter during the measurement period or the year prior

    • Taking dementia medications during the measurement period or the year prior

  • Exclude patients receiving palliative care during the measurement period.

NumeratorWomen with one or more mammograms during the 27 months prior to the end of the measurement period
Numerator Exclusions
Denominator Exceptions

Additional Information

Measure TypeProcess measure
Measure ScoringProportion measure
GranularityPatient
Improvement NotationHigher score indicates better quality
DomainEffective Clinical Care

Clinical Instructions

New UI Visit Encounter (valid RC202109+)

Original Visit Encounter

Use the Past Procedures section of the encounter to record a previous mammogram, in order to track all 50-74 year-old women with one or more mammograms recorded (15 months prior to or during the measurement period). Otherwise, the procedure can be recorded in the Preventive Care section of the encounter, or a mammogram can be scanned and indexed, to record the screening was completed.

  1. While documenting the Visit encounter, either record the previous procedure or the receipt of the mammogram, or scan and index the mammogram, as appropriate:

    1. Option 1: Document in Past Procedures section

      1. Open the Past Procedures section.
      2. Using the Procedure autocomplete, begin typing the name of the diagnostic procedure (e.g., Mammogram) with the appropriate concept ID.
      3. Add the Date and any relevant Notes.
      4. Click the Next button, or close the section.
    2. Option 2: Document in the Preventive Care section of Visit encounter

      1. Open the Preventive Care section.
      2. Provide the date of the last reported procedure in the Enter New Date field (e.g., 01-21-2018). This date is the Last Reported Date.
      3. Click the Next button, or close the section. 
  2. Continue documenting the encounter, as needed.

  3. When completed, Close and Archive the encounter.

  • Option 3: Scan/Index or Upload a Mammogram document

    • Using WebScan , scan and index the MAMMO document type configured with the necessary LOIN-C (24606-6).

Evidence

Initial Patient Population

NameValue Set
Encounter, Performed: Annual Wellness Visit2.16.840.1.113883.3.526.3.1240
Encounter, Performed: Home Healthcare Services2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed: Office Visit2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed: Online Assessments2.16.840.1.113883.3.464.1003.101.12.1089
Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up2.16.840.1.113883.3.464.1003.101.12.1025
Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up2.16.840.1.113883.3.464.1003.101.12.1023
Encounter, Performed: Telephone Visits2.16.840.1.113883.3.464.1003.101.12.1080

Denominator Exclusions

NameValue Set
Assessment, Performed: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)LOINC Code 71007-9
Device, Applied: Frailty Device2.16.840.1.113883.3.464.1003.118.12.1300
Device, Order: Frailty Device2.16.840.1.113883.3.464.1003.118.12.1300
Diagnosis: Frailty Diagnosis2.16.840.1.113883.3.464.1003.113.12.1074
Diagnosis: History of bilateral mastectomy2.16.840.1.113883.3.464.1003.198.12.1068
Diagnosis: Status Post Left Mastectomy2.16.840.1.113883.3.464.1003.198.12.1069
Diagnosis: Status Post Right Mastectomy2.16.840.1.113883.3.464.1003.198.12.1070
Diagnosis: Unilateral Mastectomy, Unspecified Laterality2.16.840.1.113883.3.464.1003.198.12.1071
Encounter, Performed: Acute Inpatient2.16.840.1.113883.3.464.1003.101.12.1083
Encounter, Performed: Care Services in Long-Term Residential Facility2.16.840.1.113883.3.464.1003.101.12.1014
Encounter, Performed: Emergency Department Visit2.16.840.1.113883.3.464.1003.101.12.1010
Encounter, Performed: Encounter Inpatient2.16.840.1.113883.3.666.5.307
Encounter, Performed: Frailty Encounter2.16.840.1.113883.3.464.1003.101.12.1088
Encounter, Performed: Nonacute Inpatient2.16.840.1.113883.3.464.1003.101.12.1084
Encounter, Performed: Nursing Facility Visit2.16.840.1.113883.3.464.1003.101.12.1012
Encounter, Performed: Observation2.16.840.1.113883.3.464.1003.101.12.1086
Encounter, Performed: Outpatient2.16.840.1.113883.3.464.1003.101.12.1087
Encounter, Performed: Palliative Care Encounter2.16.840.1.113883.3.464.1003.101.12.1090
Intervention, Order: Hospice care ambulatory2.16.840.1.113762.1.4.1108.15
Intervention, Performed: Hospice care ambulatory2.16.840.1.113762.1.4.1108.15
Intervention, Performed: Palliative Care Intervention2.16.840.1.113883.3.464.1003.198.12.1135
Medication, Active: Dementia Medications2.16.840.1.113883.3.464.1003.196.12.1510
Procedure, Performed: Bilateral Mastectomy2.16.840.1.113883.3.464.1003.198.12.1005
Procedure, Performed: Unilateral Mastectomy Left2.16.840.1.113883.3.464.1003.198.12.1133
Procedure, Performed: Unilateral Mastectomy Right2.16.840.1.113883.3.464.1003.198.12.1134
Symptom: Frailty Symptom2.16.840.1.113883.3.464.1003.113.12.1075

Numerator

NameValue Set
Diagnostic Study, Performed: Mammography2.16.840.1.113883.3.464.1003.108.12.1018

Source(s)

eCQI CMS125


Enterprise Health Documentation

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