Breast Cancer Screening

eCQM / NQF #: CMS125v7 /2372
Measure: Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer
Numerator: Women with one or more mammograms during the measurement period or the 15 months prior to the measurement period
Denominator: Women 51-74 years of age with a visit during the measurement period
Denominator Exclusion: 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 were in hospice care during the measurement year.
Domain: Effective Clinical Care


In ChartMaker Clinical:

In order to qualify for this measure, the provider must have seen the female patient (age 51-74) at least one time during the reporting period and have the appropriate information documented in the chart:

Required Data Elements for the Denominator:

Required Data Elements for the Numerator:


Exclusions include women who had a bilateral mastectomy or for whom there is evidence of two unilateral mastectomies OR were in hospice care during the measurement period.  In order to meet the requirements for the exclusion, the appropriate information must be documented in the chart:

One of the following:


•  The female patient must be 51 and older or younger than 74 before the start of the measurement period.

•  It is recommend to include the code used to document the mammogram in a health maintenance/preventive care procedure checklist.

•   If using the LOINC code for the Mammogram preformed, it must be linked to a result and must contain the date that the Mammogram was done in the procedure order date.  If a result does not exist, a fake procedure code can be added via Practice Manager and then marked as a result and linked the the appropriate LOINC Code in Clinical.

•   The LOINC code should NOT be linked to the code used to order the Mammogram. 

•  The only data used to determine the denominator is data from the ChartMaker Clinical Module. If a patient encounter was not entered into the ChartMaker Clinical Module, that encounter is not included in the denominator for the statistical calculations on the Meaningful Use Dashboard. Please add these additional patients to the denominator and recalculate the percentage for Attestation purposes.