CMS124v11 – Cervical Cancer Screening

Women 24-64 years of age by the end of the measurement period with a visit during the measurement period

– DENOMINATOR EXCLUSIONS

• Women who had a hysterectomy with no residual cervix or a congenital absence of cervix.
• Exclude patients who are in hospice care for any part of the measurement period.
• Exclude patients receiving palliative 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 two 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 four 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 24-64 at the end of the measurement period, 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
• Telephone Visits
• Online Assessments

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 > Clinical > Orders&Results > Labs and click ‘+ Add Order’ button.

Here, select a laboratory and search for the lab test. Once done, click on the ‘Save’ or ‘Sign’ button.

Next, click on the ‘Mark As Received’ button.

 On the ‘Edit Lab Result’ screen, add the observations and click on the ‘Save’ button.

Note: 

For LOINC Code Based Labs: 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’. 

For CPT Code Based Labs: 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. Click ‘Add’ and search for the procedure. Add the procedure details and click on ‘Save & Accept’/hover over ‘Sign & Accept’. If the user hovers over ‘Sign & Accept’, then click ‘Complete’. The procedure is added to the provider note.

Note:

Please ensure that the Procedure is present in the system. For this, navigate to Settings > Billing > Procedure. If the procedure is not added then, click on the ‘Add Procedure’ button.

Here, enter the ‘Code’ and ‘Name’ of the Procedure. Once done, click on the ‘Save’ button. 

• Patient is diagnosed with congenital absence of cervix. To document the diagnosis, use the workflow Patient > Provider Note > Diagnoses and click ‘Add’. Search for the diagnosis, add the diagnosis details, and click ‘Save’. Then click ‘Accept’ and the diagnosis is added to the provider note.

• 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

• • Patients with hospice care assessment performed during the measurement period. To document the assessment, follow the workflow Patient > Clinical > Evaluations. Click ‘+ Add’ and search for an evaluation. Then select ‘Performed’ from the ‘Status’ dropdown and enter ‘Yes’ in the ‘Result’ field.
  • Patients with hospice encounter during the measurement period. To document the hospice encounter, follow the workflow Patient > Clinical > Evaluations.
• Patients receiving palliative care during the measurement period.
  • To record the ‘Palliative Care Encounter’ performed, use the workflow Patient > Provider Note > eSuperbill.
  • To record the ‘Palliative Care Intervention’ performed, use the workflow Patient > Clinical > Evaluations.
  • To record the ‘Functional Assessment of Chronic Illness Therapy’ assessment performed, navigate to Patient > Clinical > Evaluations.