CMS 124 Cervical Cancer Screening
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Click the following dropdown to see what's new for this measure in 2020.
What's New in 2020
The CMS 124 Cervical Cancer Screening measure has been updated for 2020 reporting in PSR v2020.3. Here's a summary of what's changed since the 2019 reporting logic was released in PSR 2019.
All CMS measures in PSR v2020.3 use logic described in the following help topic: Identifying Event Times. Some of this logic was revised for version PSR 2020.2.
Measure Specification and Value Sets Changes
For the 2020 reporting year, the detailed measure help for this measure includes hyperlinks to the Value Sets used by this measure. You must be registered for a UMLS license and signed in to your account to see this content.
Overview
This measure reports the percentage of women 21-64 years old who were screened for cervical cancer.
- Women 21-64 years old can qualify if they had a Pap test during the measurement period or the 2 years prior to the measurement period start date.
- Women 30-64 years old at the time of their Pap test can qualify if they had both a Pap test and an HPV test during the measurement period or the 4 years prior to the measurement period start date.
At a Glance
| eMeasure ID | CMS124v8 |
| NQF | N/A |
| Used For? | Medicaid PI/Stage 3, MIPS (Quality) |
| Domain | Effective Clinical Care |
| MIPS Quality ID | 309 |
| MIPS Measure Type | Process |
| MIPS High Priority? | No |
Measure Specification and Value Sets
You should be familiar with this measure’s specification, Value Sets, and direct reference codes (if applicable). Refer to
Identifying Event Times
See Identifying Event Times for important information about the logic this dashboard uses.
Amending Signed Notes
As a best practice, Notes should not be signed until they are finalized. Amending a signed Note (by making changes to it in Prime Suite and then re-saving it) will change a patient’s qualification for this measure. Re-signing the amended Note may allow the patient to qualify again, but only if it is re-signed during the time period required by the measure.
Measure Calculations
| Initial Population | Women 23-64 years of age with a visit during the measurement period. |
| Denominator | Initial Patient Population |
| Numerator | Women with one or more screenings for cervical cancer. Appropriate screenings are defined in the Numerator section below. |
Measure Details
Initial Population/Denominator
Female patients are counted in the denominator if all the following conditions are met:
| 1. | They were 23-64 years old at the beginning of the measurement period. Patients who turned 64 years old during the measurement period will qualify. Patients who turned 65 years old during the measurement period will not qualify. Age is based on the date of birth (DOB) entered on the patient’s Information page. |
| 2. | They had at least one non-voided face-to-face encounter during the measurement period. This must be documented in the Plan or E&M section of a Note using a code from one of the following Value Sets: |
- Home Healthcare Services
- Office Visit
- Preventive Care Services-Initial Office Visit, 18 and Up
- Preventive Care Services – Established Office Visit, 18 and Up
Denominator Exclusions
Female patients will be excluded from the denominator if either of the following are true. Select a link for additional information.
- They had a hysterectomy with no residual cervix or congenital absence of cervix.
- They received hospice care during the measurement period.
When documenting in Past Surgical History (PSHx) or the Problem List, a Date of Onset should be entered using the mm/dd/yyyyy format. For PMHx and PSHx, use Code Mapper to ensure that the term you’re using has been mapped to a code from the correct Value Set (Chart > Vocab Admin > Code Mapper > select section).
Hysterectomy or Congenital Absence of Cervix
Female patients who had a hysterectomy with no residual cervix or congenital absence of cervix will be excluded from the denominator. This can be indicated by either of the following:
- They had a hysterectomy at any point in time prior to the measurement period end date. This procedure must be documented using a code from the Hysterectomy with No Residual Cervix Value Set. It should include a Procedure Date entered in the mm/dd/yyyy format. This documentation must appear in the Plan section of a Note with a status of Returned or Reviewed, in Past Surgical History (PSHx) , or with a vocabulary term in the Results or in a Flowsheet.
- They have a Congenital Absence of Cervix. This must be documented using the SNOMEDCT version 2019-05-10 direct reference code 37687000. This documentation must appear in Past Medical History (PMHx) or with a vocabulary term in the Results or in a Flowsheet.
Hospice Care
Female patients who received hospice care will be excluded from the denominator. This can be indicated by any of the following:
- They were discharged from the hospital into hospice care during the measurement period. This must be documented with a vocabulary term using a parent code from the Encounter Inpatient Value Set and a child code using either of the following SNOMEDCT version 2019-05-10 direct reference codes:
- 428371000124100 indicating a patient was Discharged to a health care facility for hospice care.
- 428361000124107 indicating a patient was Discharged to home for hospice care.
- They received hospice care. This must be documented with a vocabulary term in a Flowsheet using a code from the Hospice care ambulatory Value Set. The date the provider enters this documentation must occur during the measurement period.
- They had an order for hospice care. This must be documented in the Plan or Results section of a Note using a code from the Hospice care ambulatory Value Set. This order must have been created during the measurement period.
Numerator
Female patients must meet at least one of the following:
- They were 23-64 years old and they had a Pap test. This is indicated by a lab test documented using a value from the Pap Test Value Set. This documentation must appear with a vocabulary term in Results or in a Flowsheet. This lab test must have been administered during the measurement period or the two years prior to the measurement period start date. The patient must have been at least 21 years old at the time of the test.
- They were 30 years old or older and had two lab tests: a Pap test and a human papillomavirus (HPV) test. These lab tests must have been administered during the measurement period or the four years prior to the measurement period start date. The documentation of these tests must appear with a vocabulary term in Results or in a Flowsheet. The patient must have been at least 30 years old at the time of these tests.
- The Pap test must be documented using a code from the Pap Test Value Set.
- The human papillomavirus (HPV) test must be documented using a code from the HPV Test Value Set. This test must have been administered within 24 hours of the qualifying Pap test. This means the test must have been administered either 24 hours or less before the qualifying Pap test or up to 24 hours after the qualifying Pap test.
Numerator Exclusions
Not Applicable
Denominator Exception
None
