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      CMS124v13: Cervical Cancer Screening

      Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:

      • Women age 21-64 who had cervical cytology performed every 3 years
      • Women age 30-64 who had cervical human papillomavirus (HPV) testing performed every 5 years

      *Telehealth Eligible*

      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 at least 30 years old at the time of the test

       

      Women age 21-64 who had cervical cytology performed every 3 years

      Pap test is completed within three years of the last day of the measurement period. The PAP test can be recorded in any of the following ways:

      • Manually Imported Item or Electronically-receive results: The test name for the lab results/imported item should include one of the following phrases
        • pap test
        • pap smear
      • Clinical Decision Support Rule: The clinician completes the following rule:
        • "Screening for Cervical Cancer with Pap smear"
      • Text in the Chart: Identify a pap smear has been completed by including any of the following phrases in the Plan or Assessment fields of the Most Recent Encounter:
        • cervical cancer screening done
        • pap performed
        • pap test performed
        • pap smear performed

      Women age 30-64 who had cervical human papillomavirus (HPV) testing performed every 5 years

      Pap and HPV test completed within five years of the last day of the measurement period. The PAP and HPV tests can be recorded in any of the following ways.

      • Manually Imported Item or Electronically-receive results: There will need to be two imported items/laboratory results identified by the test names "pap test" or "pap smear". and "HPV test"
      • Clinical Decision Support Rule: The clinician completes the following rule
        • "Screening for Cervical Cancer in Women 30 years and Older"
      • Text in the Chart: Identify a pap smear has been completed by including any of the following phrases in the Plan or Assessment fields of the Most Recent Encounter:
        • cervical cancer screening done
        • pap performed
        • pap test performed
        • pap smear performed

      Denominator


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

      Denominator Exclusions

      Patients are excluded for any of the following reasons

      • Women who had a hysterectomy with no residual cervix:
        • Text in the Chart: If the PMH or PE in the Most Recent Encounter includes the phrase "total abdominal hysterectomy" or "TAH performed" they will be excluded from the denominator.
        • Diagnosis Code: If the Problem List includes an appropriate ICD-10 code.
      • Exclude patients whose hospice or palliative care overlaps the measurement period:
        • Identified in the patient's Alerts and Directives, located in the demographic screen or the Summary Sheet, in the name, text or comments saved with that alert/directive. The Alert/Directive should include either of the following phrases:
          • palliative
          • hospice