CMS 124v11: Cervical Cancer Screening

Measure: 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
Measure Type High Priority Measure Scoring
Process No A higher percentage indicates better quality
Denominator Women 24-64 years of age by the end of the measurement period with a visit 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 at least 21 years old at the time of the test
  • 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
Denominator Exceptions None
Denominator Exclusions
  • Women who had a hysterectomy with no residual cervix or a congenital absence of cervix
  • Women who are in hospice care for any part of the measurement period
  • Women receiving palliative care for any part of the measurement period

This eCQM requires a lab interface to be met. Customers interested in a lab interface should contact Sevocity Support to begin the process of a new interface setup. Interface setup requirements and fees vary per request.

Patients who meet the following criteria will be included in the denominator:

  • Have a birth sex of female

    AND

  • Age is 24 years to 64 years at the end of the Measurement Period

    AND

  • Have at least one eligible encounter during the Measurement Period finalized by the EC

CPT: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99395, 99396, 99397, 99385, 99386, 99387, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 98969, 98970, 98971, 98972, 99421, 99422, 99423, 99458, 98966, 98967, 98968, 99441, 99442, 99443

HCPCS: G0071, G2010, G2012, G2061, G2062, G2063

A patient will be excluded from this measure if they meet any of the following conditions:

  • Had a hysterectomy with no residual cervix performed any time before the end of the Measurement Period
  • Has an active or resolved diagnosis of a hysterectomy with no residual cervix
  • Has a documented medical history of congenital absence of the cervix
  • Has an active diagnosis of congenital or acquired absence of the cervix
  • Is in hospice care for any part of the Measurement Period
  • Is receiving palliative for any part of the Measurement Period

To document the performance of a hysterectomy, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

CPT: 51925, 56308, 57530, 57531, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58575, 58951, 58953, 58954, 58956, 59135

Order Status must be marked as Complete.

Diagnoses are documented in the Assessment tab of an encounter. The eligible diagnosis code for hysterectomy with no residual cervix is:

ICD-9: 618.5

  1. Go to Encounter > Past History > Structured > Medical History
  2. Select the hardcoded Congenital absence of cervix node

Diagnoses are documented in the Assessment tab of an encounter. The eligible diagnosis codes for congenital or acquired absence of cervix are:

ICD-10: Q51.5, Z90.710, Z90.712

ICD-9: 618.5, 752.43, V88.01, V88.03

To document hospice care ambulatory services, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

CPT: 99377, 99378

HCPCS: G0182

Order Status must be marked as Pending or Complete.

To document hospice care encounter services, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

HCPCS: G9996, G9473, G9474, G9475, G9476, G9477, G9478, G9479, Q5003, Q5004, Q5005, Q5006, Q5007, Q5008, Q5010, S9126, T2042, T2043, T2044, T2045, T2046

Order Status must be marked as Complete.

Palliative care services can be documented using the FACIT-Pal Questionnaire flowsheet, as an order, or as a diagnosis.

  1. Go to Encounter > Flowsheets/Labs > Standard or Chart > Flowsheets/Labs > Standard

  2. Click Add New Flowsheet

  3. Select the FACIT-Pal Questionnaire flowsheet and click Add

  4. Click Add Column

  5. Populate the patient's responses to the questions as appropriate

  6. Click OK to save

Go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

HCPCS: G9054, M1017

Order Status must be marked as Complete.

Diagnoses are documented in the Assessment tab of an encounter. The eligible diagnosis code for palliative care is:

ICD-10: Z51.5

A patient will be counted in the numerator if they received at least one screening for cervical cancer. Appropriate screenings and time frames for cervical cancer are defined as follows:

  • At least one Pap test performed during the Measurement Period or in the 2 years prior

    • The patient must be 21 years or older at the time of the test

    OR

  • For patients aged ≥ 30 years, one HPV test performed during the Measurement Period or in the 4 years prior
    • The patient must be 30 years or older at the time of the test

To document that a Pap test or an HPV test was performed, an e-Lab result for the test must be stored to the patient chart.

  1. From the Clinic Inbox, select the lab result to be stored and click View
    1. If the lab result is systematically matched to a patient, the Patient section will be populated in the lab result display
    2. If the lab result is not matched or the matched patient needs to be changed, the user will need to search for the patient
  2. Optional: click Select to search for and select a patient
  3. Select the I have verified the following lab results belong to the above patient checkbox
  4. Click Sign/Route
  5. Select the Sign checkbox and click OK

Stored e-Lab results can be viewed in the Flowsheets/Labs > Scanned/E-Labs tab of the patient chart.

https://ecqi.healthit.gov/ecqm/ec/2023/cms124v11

 

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