MIPS Clinical Quality Measures (CQMS)
MEASURE TYPE: Process – High Priority
Description
The percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancer.
Instructions
This measure is to be submitted once per performance period for female patients seen during the performance period. There is no diagnosis associated with this measure. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on services provided and the measure-specific denominator coding.
NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, 95, POS 02, POS 10) are allowable.
Measure Submission Type
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. The listed denominator criteria are 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
Adolescent females 16-20 years of age with a visit during the measurement period
Denominator Criteria (Eligible Cases):
Patients aged 16-20 years of age on date of encounter
AND
Patient encounter during the performance period (CPT or HCPCS): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0402, G0438, G0439
Denominator Exclusions:
A history of cervical cancer, HIV, or immunodeficiency any time during the patient’s history through the end of the measurement period: B20, B97.35, C53.0, C53.1, C53.8, C53.9, D06.0, D06.1, D06.7, D06.9, Z85.41, D80.0, D80.1, D80.2, D80.3, D80.4, D80.5, D80.6, D80.7, D80.8, D80.9, D81.0, D81.1, D81.2, D81.4, D81.6, D81.7, D81.89, D81.9, D82.0, D82.1, D82.2, D82.3, D82.4, D82.8, D82.9, D83.0, D83.1, D83.2, D83.8, D83.9, D84.0, D84.1, D84.81, D84.821, D84.822, D84.89, D84.9, D89.3, D89.810, D89.811, D89.812, D89.813, D89.82, D89.831, D89.832, D89.833, D89.834, D89.835, D89.839, D89.84, D89.89, D89.9, Z21
OR
Patients who use hospice services any time during the measurement period: G9805
Numerator:
Patients who received cervical cytology or an HPV test during the measurement period
Numerator Instructions:
Inverse Measure – A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.
Numerator Options:
Performance Met: Patients who received cervical cytology or an HPV test (G9806)
OR
Performance Not Met: Patients who did not receive cervical cytology or an HPV test (G9807)
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