CMS124v8 – Cervical Cancer Screening

Women 23-64 years of age with a visit during the measurement period.

– DENOMINATOR EXCLUSION

Women who had a hysterectomy with no residual cervix or a congenital absence of cervix.
Exclude patients whose hospice care overlaps the measurement period.

– NUMERATOR

Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria:

• Cervical cytology performed during the measurement period or the two years prior to the measurement period for women who are at least 21 years old at the time of the test
• Cervical cytology/human papillomavirus (HPV) co-testing performed during the measurement period or the four years prior to the measurement period for women who are at least 30 years old at the time of the test

For Denominator:
A female patient of age 23-64, with a visit in measurement period is considered for this measure. To record a Visit, navigate to Patient > Clinical > Provider Note.

From the ‘eSuperbill’ tab, enter the encounter codes. For instance, for the visit encounter, the code ‘99341’ is entered.

For Numerator:

Women with any one of the following lab tests are included in numerator.

• Pap test within three years before end of measurement period.
• For women with age equal or greater than 30, pap test AND HPV test performed during 5 years before end of measurement period.

To record PAP Test/HPV Test, navigate to Patient > Clinical > Provider Note > Orders and Results > Labs.

For Denominator Exclusions:

Women who satisfy any one of the following criteria are included in denominator:

• Hysterectomy with no residual cervix. To record this, navigate to Patient > Provider Note > eSuperbill or Patient > Clinical > Order and Results > Procedures.
• Congenital absence of cervix. To document this, navigate to Patient > Clinical > Diagnosis.
• Hospice care ambulatory performed. To record this, navigate to Patient > Clinical > Evaluations and use the below mentioned codes:

1. 385763009

2. 385765002

NOTE:
If a patient does not show up in the numerator even after a PAP test was documented for them, please ensure that the lab code is mapped to a LOINC Code.

To check the mapping, please navigate to Settings > EHR > Laboratory > Select Lab > Codes.

Search for the lab code for PAP test, go to the bottom of the page and enter the description, LOINC Code and relevant information against that lab code and click on save.