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  1. eCQM Issue Tracker
  2. CQM-7190

Inquiry Re: eCQM Measure 124 Cervical Cancer Screening

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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    • Susan Joy RN
    • Banner Health AZ
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      Thank you for your inquiry for CMS124v12, Cervical Cancer Screening (2024 Performance Period).

      Self-reporting is acceptable given that Cervical Cytology or HPV Test reports are documented in the EHR, and the data was approved for entry by the provider, using any of the codes found in the value sets "Pap Test" (OID: 2.16.840.1.113883.3.464.1003.108.12.1017) or "HPV Test" (OID: 2.16.840.1.113883.3.464.1003.110.12.1059), have a non-null result, and are performed within the required timeframe. You can reference the applicable codes containing these value sets on the Value Set Authority Center (VSAC) at https://vsac.nlm.nih.gov/. Click on the “Search Value Sets” tab and enter the value set ID to review codes included in the respective value set. Please review the measure specification logic/terminology section for detailed data requirements (see snippets below).

      Cervical Cytology Within 3 Years

      ["Laboratory Test, Performed": "Pap Test"] CervicalCytology
      where Global."LatestOf" ( CervicalCytology.relevantDatetime, CervicalCytology.relevantPeriod ) during day of Interval[start of "Measurement Period" - 2 years,
      end of "Measurement Period"]
      and CervicalCytology.result is not null
      HPV Test Within 5 Years for Women Age 30 and Older

      ["Laboratory Test, Performed": "HPV Test"] HPVTest
      where AgeInYearsAt(date from Global."LatestOf"(HPVTest.relevantDatetime, HPVTest.relevantPeriod))>= 30
      and Global."LatestOf" ( HPVTest.relevantDatetime, HPVTest.relevantPeriod ) during day of Interval[start of "Measurement Period" - 4 years,
      end of "Measurement Period"]
      and HPVTest.result is not null
      If you have questions about understanding measure requirements, you may refer to the "Guide for Reading eCQMs" for additional guidance. If you have questions regarding implementing the measure, you may refer to the "Implementation Checklist for eCQM Annual Update" for additional guidance. These resources can be found in the eCQI Resource Center ( https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=ecqm-resources&global_measure_group=eCQMs ).
      Show
      Thank you for your inquiry for CMS124v12, Cervical Cancer Screening (2024 Performance Period). Self-reporting is acceptable given that Cervical Cytology or HPV Test reports are documented in the EHR, and the data was approved for entry by the provider, using any of the codes found in the value sets "Pap Test" (OID: 2.16.840.1.113883.3.464.1003.108.12.1017) or "HPV Test" (OID: 2.16.840.1.113883.3.464.1003.110.12.1059), have a non-null result, and are performed within the required timeframe. You can reference the applicable codes containing these value sets on the Value Set Authority Center (VSAC) at https://vsac.nlm.nih.gov/ . Click on the “Search Value Sets” tab and enter the value set ID to review codes included in the respective value set. Please review the measure specification logic/terminology section for detailed data requirements (see snippets below). Cervical Cytology Within 3 Years ["Laboratory Test, Performed": "Pap Test"] CervicalCytology where Global."LatestOf" ( CervicalCytology.relevantDatetime, CervicalCytology.relevantPeriod ) during day of Interval[start of "Measurement Period" - 2 years, end of "Measurement Period"] and CervicalCytology.result is not null HPV Test Within 5 Years for Women Age 30 and Older ["Laboratory Test, Performed": "HPV Test"] HPVTest where AgeInYearsAt(date from Global."LatestOf"(HPVTest.relevantDatetime, HPVTest.relevantPeriod))>= 30 and Global."LatestOf" ( HPVTest.relevantDatetime, HPVTest.relevantPeriod ) during day of Interval[start of "Measurement Period" - 4 years, end of "Measurement Period"] and HPVTest.result is not null If you have questions about understanding measure requirements, you may refer to the "Guide for Reading eCQMs" for additional guidance. If you have questions regarding implementing the measure, you may refer to the "Implementation Checklist for eCQM Annual Update" for additional guidance. These resources can be found in the eCQI Resource Center ( https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=ecqm-resources&global_measure_group=eCQMs ).
    • CMS0124v12
    • This issue could impact our overall performance rating changing a patient's measure outcome from Not Met, Not Done to Met, Done.

      For EC eCQM Measure 124 - Cervical Cancer Screening numerator, is it allowed for a patient to self-report either a PAP or HPV test was done and self-reports the result as positive or negative?

      If patient self-reporting is allowed for this measure's numerator, shat is the minimum number and/or type of details would need to be included in the EMR documentation to sufficiently meet the numerator requirements?

            edave Mathematica EC eCQM Team
            SusanJoy Susan Joy
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