Cervical Cancer Screening

eCQM / NQF #: CMS124v7 / 0032
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. 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:

Required Data Elements for the Numerator:

Or the following:

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:

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