Cervical Cancer Screening (2022)
| eCQMs / NQF #: | CMS124v10 / XXXX |
| Measure: | Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:
|
| Numerator: | Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria:
|
| Denominator: | Women 23-64 years of age with a visit during the measurement period. |
| Denominator Exclusion: | Women who had a hysterectomy with no residual cervix or a congenital absence of cervix.
Exclude patients who are in hospice care for any part of the measurement period. Exclude patients receiving palliative care during the measurement period. |
| 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.
| CPT: | |
| Code | Description |
| 98966 | Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion |
| 98967 | Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion |
| 98968 | Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion |
| 98969 | Online assessment and management service provided by a qualified nonphysician health care professional to an established patient or guardian, not originating from a related assessment and management service provided within the previous 7 days, using the Internet or similar electronic communications network |
| 98970 | Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes |
| 98971 | Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes |
| 98972 | Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes |
| 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. |
| 99348 | Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused 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 low to moderate severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. |
| 99349 | Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval 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 moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family. |
| 99350 | Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to 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. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 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 |
| 99421 | Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes |
| 99422 | Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes |
| 99423 | Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes |
| 99441 | Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion |
| 99442 | Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion |
| 99443 | Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion |
| 99458 | Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes (List separately in addition to code for primary procedure) |
| G0071 | Payment for communication technology-based services for 5 minutes or more of a virtual (non-face-to-face) communication between an rural health clinic (rhc) or federally qualified health center (fqhc) practitioner and rhc or fqhc patient, or 5 minutes or more of remote evaluation of recorded video and/or images by an rhc or fqhc practitioner, occurring in lieu of an office visit; rhc or fqhc only |
| G2010 | Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment |
| G2012 | Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion |
| G2061 | Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes |
| G2062 | Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes |
| G2063 | Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes |
| SNOMED: | |
| Code | Description |
| 183452005 | Emergency hospital admission (procedure) |
| 185317003 | Telephone encounter (procedure) |
| 185460008 | Home visit request by patient (procedure) |
| 185462000 | Home visit request by relative (procedure) |
| 185463005 | Visit out of hours (procedure) |
| 185464004 | Out of hours visit – not night visit (procedure) |
| 185465003 | Weekend visit (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) |
| 30346009 | Evaluation and management of established outpatient in office or other outpatient facility (procedure) |
| 314849005 | Telephone contact by consultant (procedure) |
| 315205008 | Bank holiday home visit (procedure) |
| 32485007 | Hospital admission (procedure) |
| 3391000175108 | Office visit for pediatric care and assessment (procedure) |
| 37894004 | Evaluation and management of new outpatient in office or other outpatient facility (procedure) |
| 386472008 | Telephone consultation (procedure) |
| 386473003 | Telephone follow-up (procedure) |
| 401267002 | Telephone triage encounter (procedure) |
| 439708006 | Home visit (procedure) |
| 439740005 | Postoperative follow-up visit (procedure) |
| 698704008 | Home visit for rheumatology service (procedure) |
| 704126008 | Home visit for anticoagulant drug monitoring (procedure) |
| 8715000 | Hospital admission, elective (procedure) |
Denominator Exclusions:
Exclusion includes women who had a hysterectomy with no residual cervix or a congenital absence of cervix, or patients in hospice care or palliative 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) |
| 57530 | Trachelectomy (cervicectomy), amputation of cervix (separate procedure) |
| 57531 | Radical trachelectomy, 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) |
| 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) |
| 447771005 | Abdominal hysterectomy and excision of periuterine tissue (procedure) |
| 46226009 | Cervicectomy with synchronous colporrhaphy (procedure) |
| 473171009 | History of vaginal hysterectomy (situation) |
| 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 diagnosis with a valid ICD10 or SNOMED code using the Diagnosis widget in a note.
| ICD-10: | |
| Code | Description |
| Q51.5 | Agenesis and aplasia of cervix |
| V88.01 | Acquired absence of both cervix and uterus |
| V88.03 | Acquired absence of cervix with remaining uterus |
| Z90.710 | Acquired absence of both cervix and uterus |
| Z90.712 | Acquired absence of cervix with remaining uterus |
| SNOMED: | |
| Code | Description |
| 10738891000119107 | History of total hysterectomy without abnormal cervical Papanicolaou smear (situation) |
| 248911005 | Uterine cervix absent (finding) |
| 37687000 | Congenital absence of cervix (disorder) |
| 428078001 | History of total hysterectomy (situation) |
| 429290001 | History of radical hysterectomy (situation) |
| 429763009 | History of total hysterectomy with bilateral salpingo-oophorectomy (situation) |
| 723171001 | Acquired absence of cervix and uterus (disorder) |
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) |
This is captured by adding a procedure with a valid HCPCS or SNOMED code using the Procedure widget in a note.
| HCPCS: | |
| Code | Description |
| G9054 | Oncology; primary focus of visit; supervising, coordinating or managing care of patient with terminal cancer or for whom other medical illness prevents further cancer treatment; includes symptom management, end-of-life care planning, management of palliative therapies (for use in a medicare-approved demonstration project) |
| M1017 | Patient admitted to palliative care services |
| SNOMED: | |
| Code | Description |
| 305284002 | Admission by palliative care physician (procedure) |
| 305381007 | Admission to palliative care department (procedure) |
| 395669003 | Specialist palliative care treatment (regime/therapy) |
| 395670002 | Specialist palliative care treatment – inpatient (regime/therapy) |
| 395694002 | Specialist palliative care treatment – daycare (regime/therapy) |
| 395695001 | Specialist palliative care treatment – outpatient (regime/therapy) |
| 433181000124107 | Documentation of palliative care medication action plan (procedure) |
| 443761007 | Anticipatory palliative care (regime/therapy) |
| 4901000124101 | Palliative care education (procedure) |
| 713281006 | Consultation for palliative care (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: | |
| 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: | |
| Code | Description |
| 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 |
| 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 |
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.