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 *Teleheath Eligible
Note: This measure is for ACO practices only and is not used in Traditional MIPS
Numerator
Women with one or more mammograms any time on or between October 1 two years prior to the measurement period and the end of the measurement period
Mammograms are recorded the following way:
- Electronic Results: Mammograms are imported via an electronic interface to the Imported Items section. The name of the result must contain the phrase "mammo"
- Scanned Results: Mammograms are imported via scanning or importing to the Imported Items section. The name of the result must contain the phrase "mammo"
Denominator
Women 52-74 years of age by the end of the measurement period with a visit during the measurement period
Denominator Exclusion
Exclude patients whose hospice care overlaps the measurement period:
- Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy or for whom there is evidence of a right and a left unilateral mastectomy on or before the measurement period.
- Diagnosis: A problem exists with a name that includes the term "bilateral mastectom" or both "right mastectom" and "left mastectom"
- Text in Chart: In the History of the Present Illness, Past Medical History or Physical Exam containing either of the following phrases:
- "bilateral mastectom"
- "right mastectomy" and "left mastectomy"
- 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
- 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:
- Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period:
- Accomplished with adding the appropriate billing codes for Domiciliary or rest home visit for evaluation and management. The codes are 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337
- Exclude patients 66 and older by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria:
- Advanced Illness with two outpatient encounters during the measurement period or the year prior:
- Identified through a diagnosis in the chart. Note: a diagnosis alone is not enough, the DX code must be added to the assessment and attached to the visit CPT code
- OR Advanced illness with one inpatient encounter during the measurement period or the year prior
- Or taking dementia medications during the measurement period or the year prior
- Advanced Illness with two outpatient encounters during the measurement period or the year prior: