CMS 125 - Breast Cancer Screening

Overview

CMS125v8 (2020)
CMS125v9 (2021)
CMS125v10 (2022)

Identifiers

CMS eCQM ID	NQF eCQM ID	NQF	MIPS Quality ID
CMS125v10	–	2372	112

*MIE only supports data collection and reporting using eCQM specifications

Definitions

Description	Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period
Initial Patient Population	Women 51-74 years of age with a visit during the measurement period
Denominator	Equals Initial Population
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. Exclude patients who are in hospice care for any part of the measurement period. Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period. Exclude patients 66 and older with an indication of frailty for any part of the measurement period who meet any of the following criteria: Advanced illness with two outpatient encounters during the measurement period or the year prior Advanced illness with one inpatient encounter during the measurement period or the year prior Taking dementia medications during the measurement period or the year prior Exclude patients receiving palliative care during the measurement period.
Numerator	Women with one or more mammograms during the 27 months prior to the end of the measurement period
Numerator Exclusions	–
Denominator Exceptions	–

Additional Information

Measure Type	Process measure
Measure Scoring	Proportion measure
Granularity	Patient
Improvement Notation	Higher score indicates better quality
Domain	Effective Clinical Care

Clinical Instructions

New UI Visit Encounter (valid RC202109+)

Original Visit Encounter

Use the Past Procedures section of the encounter to record a previous mammogram, in order to track all 50-74 year-old women with one or more mammograms recorded (15 months prior to or during the measurement period). Otherwise, the procedure can be recorded in the Preventive Care section of the encounter, or a mammogram can be scanned and indexed, to record the screening was completed.

1. While documenting the Visit encounter, either record the previous procedure or the receipt of the mammogram, or scan and index the mammogram, as appropriate:
   1. Option 1: Document in Past Procedures section
      1. Open the Past Procedures section.
      2. Using the Procedure autocomplete, begin typing the name of the diagnostic procedure (e.g., Mammogram) with the appropriate concept ID.
      3. Add the Date and any relevant Notes.
      4. Click the Next button, or close the section.
   2. Option 2: Document in the Preventive Care section of Visit encounter
      1. Open the Preventive Care section.
      2. Provide the date of the last reported procedure in the Enter New Date field (e.g., 01-21-2018). This date is the Last Reported Date.
      3. Click the Next button, or close the section. 
2. Continue documenting the encounter, as needed.
3. When completed, Close and Archive the encounter.

• Option 3: Scan/Index or Upload a Mammogram document
  • Using WebScan , scan and index the MAMMO document type configured with the necessary LOIN-C (24606-6).

Evidence

Initial Patient Population

Name	Value Set
Encounter, Performed: Annual Wellness Visit	2.16.840.1.113883.3.526.3.1240
Encounter, Performed: Home Healthcare Services	2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed: Office Visit	2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed: Online Assessments	2.16.840.1.113883.3.464.1003.101.12.1089
Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up	2.16.840.1.113883.3.464.1003.101.12.1025
Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up	2.16.840.1.113883.3.464.1003.101.12.1023
Encounter, Performed: Telephone Visits	2.16.840.1.113883.3.464.1003.101.12.1080

Denominator Exclusions

Name	Value Set
Assessment, Performed: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)	LOINC Code 71007-9
Device, Applied: Frailty Device	2.16.840.1.113883.3.464.1003.118.12.1300
Device, Order: Frailty Device	2.16.840.1.113883.3.464.1003.118.12.1300
Diagnosis: Frailty Diagnosis	2.16.840.1.113883.3.464.1003.113.12.1074
Diagnosis: History of bilateral mastectomy	2.16.840.1.113883.3.464.1003.198.12.1068
Diagnosis: Status Post Left Mastectomy	2.16.840.1.113883.3.464.1003.198.12.1069
Diagnosis: Status Post Right Mastectomy	2.16.840.1.113883.3.464.1003.198.12.1070
Diagnosis: Unilateral Mastectomy, Unspecified Laterality	2.16.840.1.113883.3.464.1003.198.12.1071
Encounter, Performed: Acute Inpatient	2.16.840.1.113883.3.464.1003.101.12.1083
Encounter, Performed: Care Services in Long-Term Residential Facility	2.16.840.1.113883.3.464.1003.101.12.1014
Encounter, Performed: Emergency Department Visit	2.16.840.1.113883.3.464.1003.101.12.1010
Encounter, Performed: Encounter Inpatient	2.16.840.1.113883.3.666.5.307
Encounter, Performed: Frailty Encounter	2.16.840.1.113883.3.464.1003.101.12.1088
Encounter, Performed: Nonacute Inpatient	2.16.840.1.113883.3.464.1003.101.12.1084
Encounter, Performed: Nursing Facility Visit	2.16.840.1.113883.3.464.1003.101.12.1012
Encounter, Performed: Observation	2.16.840.1.113883.3.464.1003.101.12.1086
Encounter, Performed: Outpatient	2.16.840.1.113883.3.464.1003.101.12.1087
Encounter, Performed: Palliative Care Encounter	2.16.840.1.113883.3.464.1003.101.12.1090
Intervention, Order: Hospice care ambulatory	2.16.840.1.113762.1.4.1108.15
Intervention, Performed: Hospice care ambulatory	2.16.840.1.113762.1.4.1108.15
Intervention, Performed: Palliative Care Intervention	2.16.840.1.113883.3.464.1003.198.12.1135
Medication, Active: Dementia Medications	2.16.840.1.113883.3.464.1003.196.12.1510
Procedure, Performed: Bilateral Mastectomy	2.16.840.1.113883.3.464.1003.198.12.1005
Procedure, Performed: Unilateral Mastectomy Left	2.16.840.1.113883.3.464.1003.198.12.1133
Procedure, Performed: Unilateral Mastectomy Right	2.16.840.1.113883.3.464.1003.198.12.1134
Symptom: Frailty Symptom	2.16.840.1.113883.3.464.1003.113.12.1075

Numerator

Name	Value Set
Diagnostic Study, Performed: Mammography	2.16.840.1.113883.3.464.1003.108.12.1018

Source(s)

eCQI CMS125