Patients who meet the following criteria will be included in the denominator: Have a birth sex of femaleANDAge must be â¥ 51 years and < 74 years at the beginning of the Measurement PeriodANDMust have at least one encounter during the Measurement Period finalized by the EC/EP Encounter Codes Eligible for Denominator 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 HCPCS: G0438, G0439

A patient will be counted in the numerator if they received a mammogram during the Measurement Period or in the 15 months before the start of the Measurement Period. Document Mammogram Performed in the Breast Cancer Screening Flowsheet Go to Encounter > Flowsheets/Labs > Standard Flowsheets Click Add New FlowsheetSelect the Breast Cancer Screening flowsheet and click AddClick Add ColumnSelect Yes for Has the patient had a mammogram in the last two years?Populate a date for If yes, what date was it performed?Click OK to save Document Procedure for Mammogram Performed To document the performance of a mammogram as a procedure, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add any of the eligible codes listed below: HCPCS: G0202, G0204, G0206 Order Status must be marked as Complete in order to count toward the numerator.

CMS 125v7: Breast Cancer Screening

Updated June 8, 2026 3 minute read

Measure: Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer
Measure Type	High Priority Measure	Scoring
Process	No	A higher percentage indicates better quality

Denominator	Women 51-74 years of age with a visit during the measurement period
Numerator	Women with one or more mammograms during the measurement period or the 15 months prior to the measurement period
Denominator Exceptions	None
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 Whose hospice care overlaps the measurement period

Denominator

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

Have a birth sex of female
AND
Age must be â¥ 51 years and < 74 years at the beginning of the Measurement Period
AND
Must have at least one encounter during the Measurement Period finalized by the EC/EP

Encounter Codes Eligible for Denominator

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

HCPCS: G0438, G0439

Denominator Exclusions

Bilateral Mastectomy or Two Unilateral Mastectomies

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

Have an active diagnosis for two unilateral mastectomies
Have an active diagnosis for history of bilateral mastectomy
Have a documented history of a bilateral mastectomy or two unilateral mastectomies
Had a bilateral mastectomy or two unilateral mastectomies

Diagnosis

Diagnoses are documented in the Assessment tab of an encounter. A comprehensive list of eligible diagnosis codes for bilateral and unilateral mastectomies can be located here.

If documenting two unilateral mastectomies, the Anatomical Location Site must be specified when adding each diagnosis code.

History of Bilateral Mastectomy or Two Unilateral Mastectomies

To document a bilateral or two unilateral mastectomies in the patient history:

Go to Encounter > Past History > Structured > Surgical History
Select the hardcoded Mastectomy node
Select the appropriate bilateral or unilateral mastectomy type for the patient
1. If selecting a unilateral mastectomy type, both Right Breast and Left Breast must be selected
Populate the Date of Surgery for the mastectomy
Click OK to save

Bilateral Mastectomy or Two Unilateral Mastectomies Performed

Document Mastectomy Performed in the Breast Cancer Screening Flowsheet

Go to Encounter > Flowsheets/Labs > Standard Flowsheets
Click Add New Flowsheet
Select the Breast Cancer Screening flowsheet and click Add
Click Add Column
Select a Value for Patient excluded due to the following reason
Click OK to save

Document Procedure for Mastectomy Performed

To document the performance of two unilateral mastectomies as a procedure, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add any of the eligible codes listed below:

CPT: 19180, 19200, 19220, 19240, 19307, 19306, 19305, 19304, 19303

Order Status must be marked as Complete in order to count as an exclusion.

Hospice Care Services

Patients who were in hospice care during the measurement year will be excluded from the measure.

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

SNOMED CT: 385763009, 385765002

Order Status must be marked as Complete.

Note

SNOMED CT codes must be added as a Favorite in Preferences > Form Data > Orders to be accessible from the Orders/Referrals tab.

Numerator

A patient will be counted in the numerator if they received a mammogram during the Measurement Period or in the 15 months before the start of the Measurement Period.

Document Mammogram Performed in the Breast Cancer Screening Flowsheet

Go to Encounter > Flowsheets/Labs > Standard Flowsheets
Click Add New Flowsheet
Select the Breast Cancer Screening flowsheet and click Add
Click Add Column
Select Yes for Has the patient had a mammogram in the last two years?
Populate a date for If yes, what date was it performed?
Click OK to save

Document Procedure for Mammogram Performed

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

HCPCS: G0202, G0204, G0206

Order Status must be marked as Complete in order to count toward the numerator.

eCQI Reference

https://ecqi.healthit.gov/ecqm/ep/2019/cms125v7

Return to 2019 eCQMs