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CMS 125 - Breast Cancer Screening

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Updated: 09/30/2024 | Views: 2459

CMS 125 / Quality ID #112

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.

Denominator:	Women 52–74 years of age by the end of the measurement period with a visit during the measurement period. Patient’s age is calculated based on the patient’s Date of Birth, which was entered when you created the patient’s account. Create a note detailing the patient’s office visit.
Denominator Exclusions:	Women who had a bilateral mastectomy or unilateral mastectomy or have a history of bilateral mastectomy or for whom there is evidence of a right and a left unilateral Mastectomy on or before the end of the measurement period: If a "Bilateral Mastectomy" or "Unilateral Mastectomy" is documented under Hospitalizations/Procedures in History. These patients will be excluded from the denominator. Exclude patients who are in hospice care for any part of the measurement period. Hospice is documented under Hospice in History. These patients will be excluded from the denominator. Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period. Patient’s age is calculated based on the patient’s Date of Birth. Long Term Care is documented under Long Term Care Facility in History. These patients will be excluded from the denominator. Exclude patients 66 and older by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advance illness criteria: Advanced illness with two outpatient encounters during the measurement period or the year prior, OR Advanced illness with one inpatient encounter during the measurement period or the year prior, OR Taking dementia medications during the measurement period or the year prior. Patient’s age is calculated based on the patient’s Date of Birth. "Advanced Illness" and "Frailty" is documented under Problems with a Start Date. Exclude patients receiving palliative care for any part of the measurement period. Palliative Care is documented under Problems with a Start Date.
Numerator:	Women with one or more mammograms any time on or between October 1 two years prior to the measurement period and the end of the measurement period. A "Mammogram" order must be created under Labs/Studies. The clinician will have to sign the results when received. If results are not received via eLabs, the results will have to be manually added on the order created in Labs/Studies. To add a "Mammogram" previously completed by the patient, create a Lab Order Report.
Office Visit Documentation:	Enter Procedure Codes including E/M Codes, HCPCS, or CPT Codes as applicable on the Charge Capture Complete and sign the note Once all steps have been completed, the measure will be added to the Quality Measures Report.
Measure type:	Process
High Priority Measure:	No
Telehealth Eligible:	Yes