Cervical Cancer Screening (2020)

eCQM / NQF #: CMS124v8 / XXXX
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 every 3 years* Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years.
Numerator: Women with one or more screenings for cervical cancer during the measurement period or the two years prior to the measurement period. 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 cytology/human papillomavirus (HPV) co-testing performed during the measurement period or the four years prior to the measurement period for women who are at least 30 years old at the time of the test.

Denominator: Women 23-64 years of age with a visit during the measurement period.
Denominator Exclusions: Women who had a hysterectomy with no residual cervix or a congenital absence of cervix. 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 23 to 64) at least one time during the reporting period and have the appropriate information documented in the chart:

Required Data Elements for the Denominator:

This is captured by adding a procedure with a valid CPT or SNOMED code using the Procedure widget in a note.

Office Visit Encounter Codes:
CPT  
Code Description
99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.
99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.
99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.
99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.
99341 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.
99342 Home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
99343 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
99344 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
99345 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent face-to-face with the patient and/or family.
99347 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family.
99385 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years
99386 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years
99387 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older
99395 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years
99396 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years
99397 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older
Face-to-Face Interaction Codes:
SNOMED:  
Code Description
4525004 Emergency department patient visit (procedure)
12843005 Subsequent hospital visit by physician (procedure)
18170008 Subsequent nursing facility visit (procedure)
19681004 Nursing evaluation of patient and report (procedure)
87790002 Follow-up inpatient consultation visit (procedure)
90526000 Initial evaluation and management of healthy individual (procedure)
185349003 Encounter for “check-up” (procedure)
185463005 Visit out of hours (procedure)
185465003 Weekend visit (procedure)
207195004 History and physical examination with evaluation and management of nursing facility patient (procedure)
270427003 Patient-initiated encounter (procedure)
270430005 Provider-initiated encounter (procedure)
308335008 Patient encounter procedure (procedure)
390906007 Follow-up encounter (procedure)
406547006 Urgent follow-up (procedure)
439708006 Home visit (procedure)
185463005 Visit out of hours (procedure)
185464004 Out of hours visit – not night visit (procedure)
185465003 Weekend visit (procedure)
30346009 Evaluation and management of established outpatient in office or other outpatient facility (procedure)
3391000175108 Office visit for pediatric care and assessment (procedure)
37894004 Evaluation and management of new outpatient in office or other outpatient facility (procedure)
439740005 Postoperative follow-up visit (procedure)
185460008 Home visit request by patient (procedure)
185462000 Home visit request by relative (procedure)
185466002 Home visit for urgent condition (procedure)
185467006 Home visit for acute condition (procedure)
185468001 Home visit for chronic condition (procedure)
185470005 Home visit elderly assessment (procedure)
225929007 Joint home visit (procedure)
315205008 Bank holiday home visit (procedure)
439708006 Home visit (procedure)
698704008 Home visit for rheumatology service (procedure)
704126008 Home visit for anticoagulant drug monitoring (procedure)

Required Data Elements for the Numerator:

This is captured by:

•  An electronic lab result with a valid LOINC code,

•  Adding a finding with a valid LOINC code using the Checklist widget in a note,

or

•  Adding a numeric result with a valid LOINC code using a Numeric control in a note.

LOINC:  PAP TEST
Code Description
10524-7 Microscopic observation [Identifier] in Cervix by Cyto stain
18500-9 Microscopic observation [Identifier] in Cervix by Cyto stain.thin prep
19762-4 General categories [interpretation] of Cervical or vaginal smear or scraping by Cyto stain
19764-0 Statement of adequacy [interpretation] of Cervical or vaginal smear or scraping by Cyto stain
19765-7 Microscopic observation [Identifier] in Cervical or vaginal smear or scraping by Cyto stain
19766-5 Microscopic observation [Identifier] in Cervical or vaginal smear or scraping by Cyto stain Narrative
19774-9 Cytology study comment Cervical or vaginal smear or scraping Cyto stain
33717-0 Cytology Cervical or vaginal smear or scraping study
47527-7 Cytology report of Cervical or vaginal smear or scraping Cyto stain.thin prep
47528-5 Cytology report of Cervical or vaginal smear or scraping Cyto stain

Or the following:

This is captured by:

•  An electronic lab result with a valid LOINC code,

•  Adding a finding with a valid LOINC code using the Checklist widget in a note,

or

•  Adding a numeric result with a valid LOINC code using a Numeric control in a note.

LOINC:  PAP TEST
Code Description
10524-7 Microscopic observation [Identifier] in Cervix by Cyto stain
18500-9 Microscopic observation [Identifier] in Cervix by Cyto stain.thin prep
19762-4 General categories [interpretation] of Cervical or vaginal smear or scraping by Cyto stain
19764-0 Statement of adequacy [interpretation] of Cervical or vaginal smear or scraping by Cyto stain
19765-7 Microscopic observation [Identifier] in Cervical or vaginal smear or scraping by Cyto stain
19766-5 Microscopic observation [Identifier] in Cervical or vaginal smear or scraping by Cyto stain Narrative
19774-9 Cytology study comment Cervical or vaginal smear or scraping Cyto stain
33717-0 Cytology Cervical or vaginal smear or scraping study
47527-7 Cytology report of Cervical or vaginal smear or scraping Cyto stain.thin prep
47528-5 Cytology report of Cervical or vaginal smear or scraping Cyto stain

 

LOINC:  HPV TEST
21440-3 Human papilloma virus 16+18+31+33+35+45+51+52+56 DNA [Presence] in Cervix by Probe
30167-1 Human papilloma virus 16+18+31+33+35+39+45+51+52+56+58+59+68 DNA [Presence] in Cervix by Probe with signal amplification
38372-9 Human papilloma virus 6+11+16+18+31+33+35+39+42+43+44+45+51+52+56+58+59+68 DNA [Presence] in Cervix by Probe with signal amplification
59263-4 Human papilloma virus 16 DNA [Presence] in Cervix by Probe with signal amplification
59264-2 Human papilloma virus 18 DNA [Presence] in Cervix by Probe with signal amplification
59420-0 Human papilloma virus 16+18+31+33+35+39+45+51+52+56+58+59+66+68 DNA [Presence] in Cervix by Probe with signal amplification
69002-4 Human papilloma virus E6+E7 mRNA [Presence] in Cervix by NAA with probe detection
71431-1 Human papilloma virus 31+33+35+39+45+51+52+56+58+59+66+68 DNA [Presence] in Cervix by NAA with probe detection
75406-9 Human papilloma virus 16 and 18+45 E6+E7 mRNA [Presence] in Cervix by Probe with amplification
75694-0 Human papilloma virus 18+45 E6+E7 mRNA [Presence] in Cervix by NAA with probe detection
77379-6 Human papilloma virus 16 and 18 and 31+33+35+39+45+51+52+56+58+59+66+68 DNA [Interpretation] in Cervix
77399-4 Human papilloma virus 16 DNA [Presence] in Cervix by NAA with probe detection
77400-0 Human papilloma virus 18 DNA [Presence] in Cervix by NAA with probe detection
82354-2 Human papilloma virus 16 and 18+45 E6+E7 mRNA [Identifier] in Cervix by NAA with probe detection
82456-5 Human papilloma virus 16 E6+E7 mRNA [Presence] in Cervix by NAA with probe detection
82675-0 Human papilloma virus 16+18+31+33+35+39+45+51+52+56+58+59+66+68 DNA [Presence] in Cervix by NAA with probe detection

EXCLUSION DETAILS:

Exclusion includes women who had a hysterectomy with no residual cervix OR patients in hospice care during the measurement period.  In order to meet the requirements for this exclusion, the appropriate information must be documented in the chart:

This is captured by adding a procedure with a valid CPT or SNOMED code using the Procedure widget in a note.

CPT:
Code Description
51925 Closure of vesicouterine fistula; with hysterectomy
56308 Laparoscopy, surgical; with vaginal hysterectomy with or without removal of tube(s), with or without removal of ovary(s) (laparoscopic assisted vaginal hysterectomy)
57540 Excision of cervical stump, abdominal approach
57545 Excision of cervical stump, abdominal approach; with pelvic floor repair
57550 Excision of cervical stump, vaginal approach
57555 Excision of cervical stump, vaginal approach; with anterior and/or posterior repair
57556 Excision of cervical stump, vaginal approach; with repair of enterocele
58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s)
58152 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (eg, Marshall-Marchetti-Krantz, Burch)
58200 Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s)
58210 Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s)
58240 Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof
58260 Vaginal hysterectomy, for uterus 250 g or less
58262 Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)
58263 Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele
58267 Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control
58270 Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele
58275 Vaginal hysterectomy, with total or partial vaginectomy
58280 Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele
58285 Vaginal hysterectomy, radical (Schauta type operation)
58290 Vaginal hysterectomy, for uterus greater than 250 g
58291 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58292 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele
58293 Vaginal hysterectomy, for uterus greater than 250 g; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control
58294 Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele
58548 Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed
58550 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less
58552 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58553 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g
58554 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58570 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less
58571 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g
58573 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58575 Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed
58951 Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy
58953 Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking
58954 Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy
58956 Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy
59135 Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy requiring total hysterectomy
SNOMED:
Code Description
116140006 Total hysterectomy (procedure)
116142003 Radical hysterectomy (procedure)
116143008 Total abdominal hysterectomy (procedure)
116144002 Total abdominal hysterectomy with bilateral salpingo-oophorectomy (procedure)
176697007 Repair of vaginal prolapse and amputation of cervix uteri (procedure)
236888001 Laparoscopic total hysterectomy (procedure)
236891001 Laparoscopic radical hysterectomy (procedure)
24293001 Excision of cervical stump by abdominal approach (procedure)
27950001 Total hysterectomy with unilateral removal of ovary (procedure)
28301000 Manchester-Fothergill operation on uterus (procedure)
287924009 Excision of cervix stump (procedure)
307771009 Radical abdominal hysterectomy (procedure)
31545000 Total hysterectomy with unilateral removal of tube (procedure)
35955002 Radical vaginal hysterectomy (procedure)
361222003 Wertheim-Meigs abdominal hysterectomy (procedure)
361223008 Wertheim operation (procedure)
387626007 Amputation of cervix (procedure)
414575003 Laparoscopic total abdominal hysterectomy and bilateral salpingo-oophorectomy (procedure)
41566006 Excision of cervical stump by vaginal approach (procedure)
440383008 Radical amputation of cervix with bilateral total pelvic lymphadenectomy and paraaortic lymph node biopsy (procedure)
446446002 Total abdominal hysterectomy and removal of vaginal cuff (procedure)
446679008 Total laparoscopic excision of uterus by abdominal approach (procedure)
46226009 Cervicectomy with synchronous colporrhaphy (procedure)
59750000 Total hysterectomy with unilateral removal of tube and ovary (procedure)
708877008 Laparoscopic total hysterectomy using robotic assistance (procedure)
708878003 Laparoscopic radical hysterectomy using robotic assistance (procedure)
739671004 Total hysterectomy with left oophorectomy (procedure)
739672006 Total hysterectomy with right oophorectomy (procedure)
739673001 Total hysterectomy with left salpingo-oophorectomy (procedure)
739674007 Total hysterectomy with right salpingo-oophorectomy (procedure)
740514001 Total hysterectomy with right salpingectomy (procedure)
740515000 Total hysterectomy with left salpingectomy (procedure)
767610009 Total hysterectomy via vaginal approach (procedure)
767611008 Total abdominal hysterectomy using intrafascial technique (procedure)
767612001 Total hysterectomy via vaginal approach using intrafascial technique (procedure)
82418001 Manchester operation on uterus (procedure)
86477000 Total hysterectomy with removal of both tubes and ovaries (procedure)
88144003 Removal of ectopic interstitial uterine pregnancy requiring total hysterectomy (procedure)

This is captured by adding a procedure with a valid SNOMED code using the Procedure widget in a note.

385763009 Hospice care (regime/therapy)
385765002 Hospice care management (procedure)

ADDITIONAL INFORMATION:

  • To ensure the measure is only looking for a cervical cytology test only after a woman turns 21 years of age, the youngest age in the initial population is 23. Therefore, the female patient must be at least 23 years and younger than 64 years of age prior to the start of the measurement period.
  • It is recommend to include the code used to document the Pap Test in a health maintenance/preventive care procedure checklist.
  • The LOINC code for the Pap Test preformed must be linked to a result and must contain the date that the Pap Test 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 Pap Test.
  • If using the SNOMED code to indicate hysterectomy, it must be linked to an applicable entry in the patient’s surgical history.  This is done via the surgical history button in a note.
  • 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.