CMS 125 Breast Cancer Screening

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The CMS 125 Breast 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.

Denominator Exclusion Changes

The denominator exclusion logic has been updated with the following changes:

  • Patients who were 65 years old or older and spent more than 90 cumulative days in a long-term care facility will now be excluded from the denominator.
  • Patients who were 65 years old or older and had an advanced illness and frailty will be excluded from the denominator.
  • Patients who had both a right and left mastectomy are excluded from the denominator. Previously, a mastectomy of the right breast and a mastectomy of the left breast had to be documented as diagnoses. Now, both mastectomies can be documented as two procedures, two diagnoses, or as a diagnosis and a procedure.

Measure Overview

This measure reports the percentage of women who had a mammogram to screen for breast cancer. The mammogram must have occurred during the 27 months prior to the measurement period end date. Only women 51-74 years old are counted.

At a Glance

eMeasure ID CMS125v8
NQF N/A
Used For? Medicaid PI/Stage 3, MIPS (Quality)
Domain Effective Clinical Care
MIPS Quality ID 112
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 Downloading Measure Specifications and Value Sets for more information. Measure help now 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.

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.

Documenting Recorded Medications in Prime Mobile

If using Prime Mobile to document a recorded medication, you must enter a non-zero duration. Entering a duration ensures the medication's end date calculates properly and that the medication can qualify for eCQMs. Otherwise, Prime Mobile defaults the medication's end date to midnight of the date recorded. Since this can cause the medication’s end date and time to occur before its start date and time, the medication would not count towards any eCQMs looking for active medications.

Measure Calculations

Initial Population Women 51-74 years of age with a visit during the measurement period.
Denominator Equals Initial Population
Numerator Women with one or more mammograms during the measurement period or the 15 months prior to the measurement period.

Measure Details

Initial Population/Denominator

Female patients are counted in the denominator if they meet all the following:

1. They were 51-73 years old at the beginning of the measurement period. Patients who turned 74 years old during the measurement period will qualify. Patients who turned 75 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:

Denominator Exclusions

Patients will be excluded from the denominator if they meet any of the following. Select a link for additional information.

When documenting in Past Medical History (PMHx) or Past Surgical History (PSHx), 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).

Bilateral Mastectomy or Two Unilateral Mastectomies

Patients will be excluded from the denominator if they meet any of the following:

  • They had a bilateral mastectomy at any point in time prior to the measurement period end date. This can be indicated by either of the following:
    • A bilateral mastectomy procedure documented in the Past Surgical History (PSHx) or documented with a vocabulary term in the Results or in a Flowsheet. This must be documented using a code from the Bilateral Mastectomy Value Set.
    • Documentation that the patient reported having a bilateral mastectomy in the patient’s Past Medical History (PMHx) using a code from the History of bilateral mastectomy Value Set.
  • They had two unilateral mastectomy procedures (resulting in a bilateral mastectomy) at any point in time prior to the measurement period end date. This can be documented in either Orders Tracking History or Past Surgical History (PSHx), but both procedures should be documented in only one of these locations and not in both locations.
    • In Orders Tracking History, both procedures can be documented using two separate orders. Both orders must have statuses of Returned or Reviewed. These orders must be documented using codes from the Unilateral Mastectomy Value Set.
    • In Past Surgical History (PSHx), you can document that the patient reported having two unilateral mastectomies. Both procedures must be documented using codes from the Unilateral Mastectomy Value Set.
  • They had both a left and a right mastectomy procedure prior to the measurement period end date. The left mastectomy procedure must be documented using a code from the Unilateral Mastectomy Left Value Set. The right mastectomy procedure must be documented using a code from the Unilateral Mastectomy Right Value Set.
  • They had two diagnoses of status post mastectomy, one for the left breast and one for the right breast. Each diagnosis must include an onset date that occurred at any point in time prior to the measurement period end date. One diagnosis must be documented using a code from the Status Post Right Mastectomy Value Set. One diagnosis must be documented using a code from the Status Post Left Mastectomy Value Set. Each diagnosis can be indicated by one of the following:
    •  A diagnosis documented in the Assessment section of a Note.
    • An active diagnosis documented in Past Medical History (PMHx) on the Facesheet. The diagnosis must be documented with a valid onset date. Note that if the diagnosis is entered in Past Medical History (PMHx), the diagnosis will remain in the patient's history indefinitely. The only way to end the diagnosis is to add it through the Problem List and enter a resolved date or inactivate it.
    • An active, resolved, or inactive diagnosis documented on the Problem List. The diagnosis must be documented with a valid onset date. If resolved, the diagnosis must also have a valid resolved date.
    • A vocabulary term in the Results or in a Flowsheet.
  • They had two diagnoses of unilateral mastectomy, unspecified laterality: one for the right breast and one for the left breast. Each diagnosis must include a result date that occurred at any point in time prior to the measurement period end date. Each must be documented with a vocabulary term in the Results or in a Flowsheet.
    • One diagnosis must have an anatomical location site of right. It must be documented as a vocabulary term with a parent code from the Unilateral Mastectomy, Unspecified Laterality Value Set and a child code from the Right Value Set.
    • One diagnosis must have an anatomical location site of left. It must be documented as a vocabulary term with a parent code from the Unilateral Mastectomy, Unspecified Laterality Value Set and a child code from the Left Value Set.

Hospice Care

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.

Long Term Care

Patients who spent more than 90 days cumulatively in long term care during the measurement period will be excluded from the denominator. They must meet each of the following:

1. They were 65 years old or older at the beginning of the measurement period, based on the date of birth (DOB) entered on the Information page.
2. They spent more than 90 cumulative days in a long-term care facility during the measurement period, documented with an encounter. This encounter can be documented in a clinical note linked to a single day visit for each day the patient was in the long-term care facility or a clinical note linked to a multi-day visit. A single day visit must have a duration of 24 hours or greater to qualify. This means that the visit's end date must not occur less than 24 hours after the visit's start date. The encounter must be documented using codes from either of the following Value Sets:

Advanced Illness and Frailty

Patients with advanced illness and frailty during the measurement period will be excluded from the denominator. This must be indicated by each of the following:

1. They were 65 years old or older at the beginning of the measurement period, based on the date of birth (DOB) entered on the Information page.
2. They had a device, diagnosis, or symptoms of frailty. This must be indicated by any of the following:
  • An order for a device related to frailty created during the measurement period, documented in the Plan section of a Note, using codes from the Frailty Device Value Set.
  • A device related to frailty was applied that overlapped the measurement period. This device must be documented in the Frailty widget, using codes from the Frailty Device Value Set.
  • A diagnosis of frailty that overlapped the measurement period. This diagnosis must be documented using a code from the Frailty Diagnosis Value Set. This can be indicated by either of the following:
    • An active diagnosis documented in Past Medical History (PMHx) on the Facesheet. The diagnosis must be documented with a valid onset date. Note that if the diagnosis is entered in Past Medical History (PMHx), the diagnosis will remain in the patient’s history indefinitely. The only way to end the diagnosis is to add it through the Problem List and enter a resolved date or inactivate it.
    • An active, resolved, or inactive diagnosis on the Problem List. The diagnosis must be documented with a valid onset date. If resolved, the diagnosis must also have a valid resolved date.
  • A frailty encounter that overlapped the measurement period, documented in the Plan or E&M section of a Note, using a code from the Frailty Encounter Value Set.
  • A symptom of frailty that overlapped the measurement period, documented in the Frailty widget, using codes from the Frailty Symptom Value Set. They symptom must be documented with a valid onset date. If resolved, the symptom must also have a valid resolved date.

To overlap the measurement period, one of the following must be true: either its start date and time or end date and time occurred during the measurement period, both its start date and time and end date and time occurred during the measurement period, or its start date and time occurred before the beginning of the measurement period and its end date and time occurred after the end of the measurement period.

3. They meet one of the following:
  • They had two outpatient encounters for advanced illness. These encounters must meet each of the following:
a. Each encounter must begin two years or less before the end of the measurement period.
b. Each encounter must be documented in the Plan or E&M section of a Note, using a code from one of the following Value Sets:
c. Each encounter must include a diagnosis of advanced illness documented using a code from the Advanced Illness Value Set.
  • They had one inpatient encounter for advanced illness. This encounter must meet each of the following:
a. The encounter began two years or less before the end of the measurement period.
b. This encounter must be documented in the Plan or E&M section of a Note, using a code from the Acute Inpatient Value Set.
c. The encounter must include a diagnosis of advanced illness documented using a code from the Advanced Illness Value Set.
  • They had a prescription for a dementia medication that overlapped the measurement period or the year prior to the measurement period. This means that one of the following must be true: either its start date and time or end date and time occurred during the measurement period or the year prior to the measurement period, both its start date and time and end date and time occurred during the measurement period or the year prior to the measurement period, or its start date and time occurred before the beginning of the year prior to the measurement period and its end date and time occurred after the end of the measurement period. This can be documented in the Medication List as either a prescribed medication or recorded medication, using codes from the Dementia Medications Value Set.

Numerator

Patients are counted in the numerator if they had a mammogram during the 27 months prior to the measurement period end date.

Qualifying mammograms CANNOT occur on the last day of the measurement period. They must occur prior to the last day of the measurement period.

This can be indicated by either of the following:

  • An order, documented using codes from the Mammography Value Set. In Orders Tracking History, this order must have a status of Returned or Reviewed.
  • A result value documented using one of the codes from the Mammography Value Set. This must be documented with a vocabulary term in the Results or in a Flowsheet.

Numerator Exclusions

Not applicable.

Denominator Exception

None