Contents
Measure Details
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 (Pap Test) performed within the last 3 years
- Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years
ℹ️ ADDITIONAL CMS GUIDANCE
- To ensure the measure is only looking for a cervical cytology test only after a woman turns 21 years of age, the youngest age in the initial population is 23.
- The measure may include screenings performed outside the age range of patients referenced in the initial population. Screenings that occur prior to the measurement period are valid to meet measure criteria.
- Evidence of hrHPV testing within the last 5 years also captures patients who had co-testing; therefore additional methods to identify co-testing are not necessary.
Measure Parameters
Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria:
- Cervical cytology (Pap Test) performed during the measurement period or the two years prior to the measurement period for women who are at least 24-64 years of age by the end of the measurement period.
- 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.
Women 24-64 years of age with a visit during the measurement period.
Exclusions/Exceptions
- Exclude 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 for any part of the measurement period.
Elation Workflows
| 1 |
Click Address in the Cervical Cancer Screening is due reminder at the top of the visit note draft.
|
| 2a |
To immediately meet the numerator requirements by documenting a test for the patient
- Click Document existing screening results.
- Record the details of a Pap Smear or HPV Test:
- Enter the date of the test in the Date field.
- Select the appropriate document tag in the Type field:
- Pap Smear (result: negative)
- Pap Smear (result: positive)
- HPV Test (result: negative)
- HPV Test (result: positive)
- Click + Link a report to this item to link the test results in the patient's chart to the record.
- Click Save New.
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| 2b |
To work toward meeting the numerator requirements:
- Click Order Pap Smear to create a lab order for the patient.
- Click Order HPV Test to create a lab order for the patient.
- Click Send office message to follow-up on open order to have staff follow up on an outstanding lab order.
Once the test is completed and you have the results, return to Step 2a.
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| 2c |
To exclude the patient due to a hysterectomy with no residual cervix or a congenital absence of the cervix, select one of the applicable exclusion options below. The corresponding document tag will automatically be appended to the visit note to exclude the patient from the measure.
- Document exclusion: patient had a hysterectomy
- Document exclusion: patient has congenital or acquired absence of cervix
Click here for instructions on how to document other exclusions/exceptions.
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Clicking Dismiss will dismiss the reminder and the reminder will not appear again until a new visit note draft is opened.
| 1 | Click on Cervical Cancer Screening in the Health Maintenance section of the Clinical Profile. |
| 2 | Enter the date of the test in the Date field. |
| 3 |
Select the appropriate document tag in the Type field:
- Pap Smear (result: negative)
- Pap Smear (result: positive)
- HPV Test (result: negative)
- HPV Test (result: positive)
|
| 4 |
Click + Link a report to this item to link the test results in the patient's chart to the record.
|
| 5 |
Click Save New.
|
| 1 | Open the test results in the patient's chart. |
| 2 | Click Actions -> Edit Details. |
| 3 |
Go to the Tags field and select the appropriate document tag below:
- Pap Smear (result: negative)
- Pap Smear (result: positive)
- HPV Test (result: negative)
- HPV Test (result: positive)
|
| 4 | Click Save. |
| Exclusion/Exception | Step(s) |
| Exclude women who had a hysterectomy with no residual cervix or a congenital absence of cervix. |
Click + Tag at the bottom of the visit note draft and add the appropriate document tag from this list:
- EXCLUSION: HYSTERECTOMY
- CQM EXCL: CONGENITAL ABS OF CERVIX
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|
Patients whose hospice care overlaps the measurement period.
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Click + Tag at the bottom of the visit note draft and add the appropriate document tag from this list:
- EXCLUSION: HOSPICE CARE
- EXCLUSION: IP DISCHARGE STATUS TO HEALTH CARE FACILITY FOR HOSPICE CARE
- EXCLUSION: IP DISCHARGE STATUS TO HOME FOR HOSPICE CARE
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| Patients receiving palliative care for any part of the measurement period. |
Click + Tag at the bottom of the visit note draft and add the following document tag - EXCLUSION: PALLIATIVE CARE
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Measure Information
All women are at risk for cervical cancer. In 2020, an estimated 13,800 women were diagnosed with cervical cancer in the U.S., resulting in an estimated 4,290 deaths (National Cancer Institute, 2020). Screening can identify precancerous lesions and can detect invasive cancer early, when treatment is more likely to be successful (American Cancer Society, 2020).
Reference: Measure Information from CMS
What test codes are linked to the Pap Smear and HPV Tests?
The following test LOINC codes qualify for these screenings
- Pap Smear - 10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5
- HPV Test - 21440-3, 30167-1, 38372-9, 59263-4, 59264-2, 59420-0, 69002-4, 71431-1, 75694-0, 77379-6, 77399-4, 77400-0, 82354-2, 82456-5, 82675-0, 95539-3
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