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

Quality ID

225

NQF

0509

High Priority Measure

Yes

Specifications

Registry

Measure Type

Structure

Specialty

Diagnostic Radiology

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 or HCPCS): 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 (e.g., 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)

 

Rationale

Although screening mammograms can reduce breast cancer mortality by 20-35% in women aged 40 years and older, recent evidence shows that only 72% of women are receiving mammograms based on current guideline recommendations. The use of patient reminders is associated with an increase in screening mammography.

Encouraging the implementation of a reminder system could lead to an increase in mammography screening at appropriate intervals.

 

Clinical Recommendation Statements

The Community Preventive Services Task Force recommends the use of client reminders to increase screening for breast and cervical cancers on the basis of strong evidence of effectiveness (CPSTF, 2010)

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