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CMS 125 - Breast Cancer Screening

Updated: 11/11/2020
Views: 1471

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 51 through 74 years of age 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:
  • If a "Bilateral Mastectomy" or "Unilateral Mastectomy" is documented under Hospitalizations/Procedures in History. These patients will be excluded from the denominator.

If patient was in Hospice during the measurement period:

Exclude patients 66 and older who are living long term in an institution for more than 90 days during the measurement period:

Exclude patients 66 and older with advanced illness and frailty because it is unlikely that patients will benefit from the services being measured:

  • 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.
Numerator: Women with one or more mammograms during the 27 months prior to 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:

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