2021 MIPS Measure #225: Radiology: Reminder System for Screening Mammograms

Measure Description

Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram

Instructions

This measure is to be submitted each time a screening mammogram is performed during the performance period for patients seen during the performance period. This measure is intended to reflect the quality of services provided for reminding patients when follow-up mammograms are due.

Measure Submission Type:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

Denominator

All patients undergoing a screening mammogram

Denominator Criteria (Eligible Cases):

All patients, regardless of age

AND

Diagnosis for mammogram screening (ICD-10-CM): Z12.31

AND

Patient procedure during the performance period (CPT): 77067

Numerator

Patients whose information is entered into a reminder system with a target due date for the next mammogram

Numerator Instructions:

The reminder system should be linked to a process for notifying patients when their next mammogram is due and should include the following elements at a minimum: patient identifier, patient contact information, dates(s) of prior screening mammogram(s) (if known), and the target due date for the next mammogram. Use of the reminder system is not required to be documented within the final report to meet performance for this measure.

Numerator Options:

Performance Met: Patient information entered into a reminder system with a target due date for the next mammogram (7025F) OR

Denominator Exception:

Documentation of medical reason(s) for not entering patient information into a reminder system (eg, further screening mammograms are not indicated, such as patients with a limited life expectancy, other medical reason(s)) (7025F with 1P)

OR

Performance Not Met:

Patient Information not entered into a reminder system, reason not otherwise specified (7025F with 8P)