Contents
ℹ️ NOTE
This measure has been removed as an eCQM for Traditional MIPS reporting.
It remains an applicable eCQM for other programs and will continue to be available in Elation. However, it will
not be eligible to count toward Traditional MIPS submissions via QRDA for the 2026 MIPS Performance Year. For a list of 2026 MIPS eligible eCQMs, see our
MIPS (2026) Overview article.
Measure Details
Percentage of women 40-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period.
New in 2026: Stratification
Report a total rate, and each of the following age strata:
- Stratum 1: Patients age 42-51 by the end of the measurement period
- Stratum 2: Patients age 52-74 by the end of the measurement period
Measure Parameters
Women with one or more mammograms any time on or between October 1st two years prior to the measurement period and end of the measurement period
Denominator
Women 42-74 years of age with a visit by the end of the measurement period.
Exclusions/Exceptions
- Exclude 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 end of the measurement period.
- Exclude patients whose hospice care overlaps the measurement period.
- Exclude patients receiving palliative care for any part of the measurement period.
- 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.
- Exclude patients 66 and older by the end of the measurement period with indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria:
- Advanced illness diagnosis during the measurement period or the year prior
- OR taking dementia medications during the measurement period or the year prior
Elation Workflows
| 1 |
Click Address in the Breast Cancer Screening is due reminder at the top of the visit note draft.
|
| 2a |
To immediately meet the numerator requirements by documenting a mammogram for the patient
- Click Document existing Mammogram details.
- Record the details of a previous mammogram:
- Enter the date of the mammogram in the Date field.
- Select the Mammogram (Effective 2022 and later) document tag in the Type field.
- Click + Link a report to this item to link mammogram report in the patient's chart to the record.
- Click Save New.
|
| 2b |
To move closer to meeting the numerator requirements:
- Click Order Mammogram to create a mammogram imaging order for the patient.
- Click Send office message to follow-up on open order to have staff follow up on an outstanding mammogram imaging order.
Once the mammogram is completed and you have the results, return to Step 2a.
|
| 2c |
To exclude the patient from the measure because they had a bilateral mastectomy, click Address in the Breast Cancer Screening is due reminder at the top of the visit note draft and then click Document exclusion: patient had a bilateral mastectomy.
- The EXCLUSION: NO BSC SCRN BIL MAST document tag will automatically be appended to the visit note to exclude the patient from the measure.
Click here for instructions on how to document other exclusions/exceptions.
|
Clicking Dismiss will dismiss the reminder and the reminder will not appear again until a new visit note draft is opened.
| 1 | Click on Breast Cancer Screening in the Health Maintenance section of the Clinical Profile. |
| 2 | Enter the date of the mammogram in the Date field. |
| 3 | Select the Mammogram (Effective 2022 and later) document tag in the Type field. |
| 4 | Click + Link a report to this item to link mammogram report in the patient's chart to the record. |
| 5 | Click Save New. |
| 1 | Open the mammogram report in the patient's chart. |
| 2 | Click Actions -> Edit Details. |
| 3 |
Go to the Tags field and select the Mammogram (Effective 2022 and later) document tag.
|
| 4 | Click Save. |
| Exclusion/Exception | Document Tag(s) |
| 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 end of the measurement period. |
Click + Tag at the bottom of the visit note draft and add the appropriate document tag from this list:
- EXCLUSION: NO BSC SCRN Absence of Left Breast
- EXCLUSION: NO BSC SCRN Absence of Right Breast
- EXCLUSION: NO BSC SCRN BIL MAST
- EXCLUSION: NO BSC SCRN UNI MAST
|
|
Patients whose hospice care overlaps the measurement period.
|
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
|
| 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 |
| 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. | Click + Tag at the bottom of the visit note draft and add the following document tag - EXCLUSION: Living Long Term in a Nursing Home |
|
Exclude patients 66 and older by the end of the measurement period with indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria:
- Advanced illness diagnosis during the measurement period or the year prior
- OR taking dementia medications during the measurement period or the year prior
| See below. |
Documenting frailty
To document frailty in Elation using
- Frailty diagnosis, advanced illness codes and/or medications
- Add a frailty diagnosis to the Problem List. You must select from one of the frailty codes listed here.
- Record one of the following:
- an advanced illness diagnosis in 2 outpatient encounters using one of the codes listed here.
- an advanced illness in 1 inpatient counter using one of the codes listed here.
- a dementia medication in the patient's chart.
- A frailty device code
- Click + Tag at the bottom of the visit note draft.
- Create/add the appropriate document tag for the relevant frailty device from this list of frailty device codes.
- If you are creating the document tag for the first time for a frailty device, make sure the document tag has the device's HCPCS code listed.
Measure Information
Breast cancer is one of the most common types of cancers, accounting for 15 percent of all new cancer diagnoses in the U.S. (Noone et al, 2018). In 2015, over 3 million women were estimated to be living with breast cancer in the U.S. and it is estimated that 12 percent of women will be diagnosed with breast cancer at some point during their lifetime (Noone et al, 2018).
While there are other factors that affect a woman's risk of developing breast cancer, advancing age is a primary risk factor. Breast cancer is most frequently diagnosed among women ages 55-64; the median age at diagnosis is 62 years (Noone et al, 2018).
The chance of a woman being diagnosed with breast cancer in a given year increases with age. By age 40, the chances are 1 in 68; by age 50 it becomes 1 in 43; by age 60, it is 1 in 29 (American Cancer Society, 2017).
Reference: Measure information from CMS
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