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  2. CQM-7191

For 124 Cervical Cancer Screening, does documentation of a "Hysterectomy" not defined meet Exclusion criteria?

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

      The denominator excludes "Women who had a hysterectomy with no residual cervix or a congenital absence of cervix." The value sets "Hysterectomy with No Residual Cervix" (OID: 2.16.840.1.113883.3.464.1003.198.12.1014) and "Congenital or Acquired Absence of Cervix" (OID: 2.16.840.1.113883.3.464.1003.111.12.1016) provide the values that are utilized in the measure logic. 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. Additionally, the measure logic specification’s below:

      Absence of Cervix

      ( ["Procedure, Performed": "Hysterectomy with No Residual Cervix"] NoCervixProcedure
          where Global."NormalizeInterval" ( NoCervixProcedure.relevantDatetime, NoCervixProcedure.relevantPeriod ) ends on or before
          end of "Measurement Period"
      )
        union ( ["Diagnosis": "Congenital or Acquired Absence of Cervix"] NoCervixDiagnosis
            where NoCervixDiagnosis.prevalencePeriod starts on or before
            end of "Measurement Period"
        )
      These codes must be documented in structured fields of EHR, as well as their date/time, for measure evaluation. If you have questions about reading the measure specification or understanding data 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). The denominator excludes "Women who had a hysterectomy with no residual cervix or a congenital absence of cervix." The value sets "Hysterectomy with No Residual Cervix" (OID: 2.16.840.1.113883.3.464.1003.198.12.1014) and "Congenital or Acquired Absence of Cervix" (OID: 2.16.840.1.113883.3.464.1003.111.12.1016) provide the values that are utilized in the measure logic. 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. Additionally, the measure logic specification’s below: Absence of Cervix ( ["Procedure, Performed": "Hysterectomy with No Residual Cervix"] NoCervixProcedure     where Global."NormalizeInterval" ( NoCervixProcedure.relevantDatetime, NoCervixProcedure.relevantPeriod ) ends on or before     end of "Measurement Period" )   union ( ["Diagnosis": "Congenital or Acquired Absence of Cervix"] NoCervixDiagnosis       where NoCervixDiagnosis.prevalencePeriod starts on or before       end of "Measurement Period"   ) These codes must be documented in structured fields of EHR, as well as their date/time, for measure evaluation. If you have questions about reading the measure specification or understanding data 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 patient's outcome from Not Met, Not Done to Exclusion

      For 124 Cervical Cancer Screening, could documentation of a "Hysterectomy" without a defined status of cervix removal meet Exclusion criteria?  For example, if it read "Total Hysterectomy, I know that indicates both uterus and cervix was removed.

      Is there coding that might identify "Hysterectomy" as written that included cervix removal?  

      I would say no - that Hysterectomy documented by itself - would not count as a true exclusion but wanted to check to be sure.  Is 

            edave Mathematica EC eCQM Team
            SusanJoy Susan Joy
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