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[CMS125v6] NQF 2372 Breast Cancer Screening

Last Updated: Jun 26, 2019 02:56AM PDT

1. Measure Details
2. Measure Parameters
3. Meeting the Measure in Elation
4. Measure Information

1. Measure Details

Report on the percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.

2. Measure Parameters:
Numerator: Women with one or more mammograms during the measurement period or the 15 months prior to the measurement period.

Denominator: Women 51-74 years of age with a visit during the measurement period.

Exclusions/Exceptions: 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.

How to satisfy measure in Elation: Use Document tags "CQM Mammogram (result: positive)" or "CQM Mammogram (result: negative)"

2. Elation Workflows

Recording from a visit note:

1/ While documenting a visit note, if the patient requires a breast cancer screening, a Clinical Reminders alert will appear at the top of the visit note.

2/ On the right hand side of this alert, you'll be given an option to address or dismiss the alert. Clicking Address will bring up options to address the measure.

3/ When addressing the alert, the only option that will include the patient in the numerator is the "Document existing Mammogram details" option, which will give you a prompt to record the details of a previous mammogram. If they haven't had a mammogram in the measurement, the prompt also gives the options to order a mammogram, or to direct the clinic staff to order one.

Recording from a patient chart:

1/ At the bottom of the clinical profile, in the lower left corner of the patient's chart, you'll see the patient's active Health Maintenance items.

2/ If the patient is eligible for the breast cancer screening measure, an alert will appear in the Health Maintenance section. If it's due within the calendar year, a due date will appear in orange to the right of the measure.

3/ To document and address the measure, click on Breast Cancer Screening, and indicate the date of the patient’s most recent Mammogram, the actual result, and click Save New.


1/ Tag any document in the patient’s record with a result-defined “CQM Mammogram” document tag. This alone will meet the health maintenance requirement.

4. Measure Information

Breast cancer is one of the most common types of cancers, accounting for a quarter of all new cancer diagnoses for women in the U.S. It ranks as the second leading cause of cancer-related mortality in women, and accounted for nearly 40,000 estimated deaths in 2013. According to the National Cancer Institute's Surveillance Epidemiology and End Results program, the chance of a woman being diagnosed with breast cancer in a given year increases with age. By age 30, it is one in 2,212. By age 40, the chances increase to one in 235, by age 50, it becomes one in 54, and, by age 60, it is one in 25.
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