CMS125 / #112 — Breast cancer screening

Women who had a mammogram to screen for breast cancer in the 27 months before the end of the measurement period.

Denominator

• Female. Accept both SNOMED and HL7 administrative-gender codes.
• Age: 41–74 at the start of the period for the MIPS CQM, 42–74 at the end of the period for the eCQM. (A narrower age range that appears in the specification may be a stratification, not the denominator.)
• A qualifying encounter in the measurement period.

Numerator

A mammogram (Mammography value set) dated from 1 October two years before the measurement year through 31 December of the measurement year.

Look in several places — EHRs record mammograms differently:

• DiagnosticReport and Procedure with a code in the value set;
• the report title or code.text mentioning “mammogram” (a text fallback for poorly coded EHRs);
• Observation (text only);
• Condition resources on EHRs that store screenings as conditions (see Practice Fusion).

Use every candidate date found across these sources, and take the most recent within the window.

Exclusions

• Bilateral mastectomy, or a left and a right unilateral mastectomy (on different dates). Make sure the left-plus-right case is actually reachable in your logic — it is easy to write a rule that can never fire.
• Hospice, palliative care, age 66+ in long-term care, and age 66+ with frailty plus advanced illness or dementia medication.

Encounter qualification

When an EHR’s encounter types don’t match the value sets, a strict check excludes nearly every patient. Falling back to the latest completed encounter in the period keeps eligible patients in the denominator — flag results calculated this way.