[CQM-7272] For eCQM Measure 124-Cervical Cancer Screening, Need clarification of Numerator criteria related to cervical cytology testing Created: 09/23/24 Updated: 10/01/24 Resolved: 10/01/24 |
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| Status: | Closed |
| Project: | eCQM Issue Tracker |
| Component/s: | None |
| Type: | EC eCQMs - Eligible Clinicians | Priority: | Moderate |
| Reporter: | Susan Joy (Inactive) | Assignee: | AIR EC eCQM Team |
| Resolution: | Answered | Votes: | 0 |
| Labels: | None | ||
| Contact Name: | Susan Joy RN |
| Contact Email: | susan.joy@bannerhealth.com |
| Institution/Name: | Banner Health Arizona |
| Solution: | Thank you for your inquiry for CMS124v12 (2024 Performance Period). According to the measure steward, the National Committee for Quality Assurance (NCQA), to meet the Numerator criteria for this measure, simply having a Pap test performed is not sufficient. Cervical Cytology or HPV Test reports must be documented in EHR 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 performed within the required timeframe.
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=0. |
| Solution Posted On: | |
| 2024 Performance Period EC eCQMs: |
CMS0124v12
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| Impact: | This could affect our overall performance rating in relation to achieving our submission criteria. |
| Description |
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Per eCQM specification 124: "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 within the last 3 years - Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years." A "Pap Test," or cervical scraping, is a procedure done for multiple reasons that can also include cervical cytology. In order to meet the Numerator for measure 124, does just getting a Pap test done by itself meet the numerator? Or does the test result /report also have to include a cervical cytology or cervical cancer screening actual result to indicate the test was performed for cervical cytology? |
| Comments |
| Comment by AIR EC eCQM Team [ 09/30/24 ] |
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We continue to investigate the issue noted in your ticket and will provide a response as soon as we are able. Thank you for your patience. |
| Comment by AIR EC eCQM Team [ 09/23/24 ] |
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Thank you for submitting your question. We will review your ticket and provide a response as soon as possible. |