CMS124v9 – Cervical Cancer Screening

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

– DENOMINATOR EXCLUSION

• Women who had a hysterectomy with no residual cervix or a congenital absence of cervix.
• Women who were in hospice care during 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 2 years prior to the measurement period for women who are at least 21 years old at the time of the test.
• Cervical human papillomavirus (HPV) testing performed during the measurement period or the 4 years prior to the measurement period for women who are 30 years or older at the time of the test.

For Denominator:

A female patient of age 23-64, with a visit during the measurement period is considered for this measure. To record an encounter, navigate to Patient > Provider Note > eSuperbill. Under the ‘Procedures- CPTs’ heading, enter the encounter code.

• Office Visit
• Home Healthcare Services
• Preventive Care Services – Initial Office Visit, 18 and Up
• Preventive Care Services – Established Office Visit, 18 and Up

For Numerator:

Female patient satisfying any one of the following conditions are included in the numerator:

• Patient is 21 years of age or older and received a Pap test in a three-year period.
• Patient is 30 years of age or older and has a HPV test performed during the measurement year or during the four years prior to the measurement year.

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

Note: Please ensure that the lab code is mapped to a LOINC Code from the Settings. To map a LOINC with the lab code, navigate to Settings > EHR > Laboratory. Select the Lab and navigate to the ‘Code’ tab. Then, click on the Lab Order. Under the ‘Result Codes and LOINCS’ heading, add a Code, LOINC and Description and click on the ‘Add’ button.

Once done, click on ‘Save’. 

When a CPT code is added to a lab order, please ensure that the CPT code is present in the ‘Procedures’. 

Moreover, the CPT code should be mapped to a LOINC Code from the Settings. To map a LOINC with the CPT code, navigate to Settings > Billing > Procedure. Select the CPT code and navigate to the ‘Edit Procedure’ tab. Under the ‘Procedure Components’ heading, add a Code, LOINC and Description and click on the ‘Add’ button.

Once done, click on ‘Save’. 

For Denominator Exclusions:

Women who satisfy any one of the following criteria are excluded from the denominator.

• Hysterectomy with no residual cervix performed on patient. To record this, navigate to Patient > Provider Note > Orders > Procedures.

Note: Please ensure that the Procedure is present in the System. To add a procedure, navigate to Settings > Billing > Procedure.

• Patient is diagnosed with congenital absence of cervix. To document this, navigate to Patient > Clinical > Diagnosis

• Patients who were in hospice care during the measurement year. To document that patient is receiving hospice care outside of a hospital or long term care facility, navigate to Patient > Clinical > Evaluations. Use the below mentioned codes to order or perform an intervention:
  • 385763009: Hospice Care (Regime/Therapy)
  • 385765002: Hospice Care Management (Procedure)

• • To document an encounter inpatient, navigate to Patient > Clinical > Evaluations