2024 MIPS Measure #443: Non-Recommended Cervical Cancer Screening in Adolescent Females

Quality ID 443

High Priority Measure Yes

Specifications Registry

Measure Type Process

Registry Link Registry

Specialty Family Medicine Internal Medicine Obstetrics/Gynecology

Measure 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

AND NOT

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

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)

Performance Not Met: Patients who did not receive cervical cytology or an HPV test (G9807)

Rationale

This measure assesses the percentage of female adolescents 16–20 years of age who were unnecessarily screened for cervical cancer. A lower rate indicates better performance for this measure.

There are multiple medical societies and evidence‐based guidelines which recommend against cervical cancer screening in a general population of females under 21 years of age; however, fewer than 25 percent of clinicians provide care consistent with guidelines (Yabroff 2009). Although screening has been shown to be highly effective in the 21–65 age group, the USPSTF determined there is adequate evidence that screening women younger than 21— regardless of sexual history—does not reduce the incidence and mortality of cervical cancer, compared with beginning screening at 21 (Moyer 2012). The USPSTF found evidence that screening in the younger age group leads to more harm than benefit because abnormal cellular changes are likely to be transient and to resolve on their own, and resulting treatment may have an adverse effect on future child‐bearing. Thus, the USPSTF specifically recommends against screening women under 21 years of age (Moyer 2012).

Moyer, V.A., U.S. Preventive Services Task Force. 2012. “Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement.” Ann Intern Med. 156(12):880-91.

Yabroff, K.R., M. Saraiya, H.I. Meissner, et al. 2009. “Specialty Differences in Primary Care Physician Reports of Papanicolaou Test Screening Practices: A National Survey, 2006 to 2007.” Ann Int Med. 151(9):602‐11.

Clinical Recommendation Statements

The United States Preventive Services Task Force (Moyer 2012):

“The USPSTF recommends against screening for cervical cancer in women younger than age 21 years (D recommendation).”

American College of Obstetricians and Gynecologists (2012):

“Cervical cancer screening should begin at age 21 years. Women younger than age 21 years should not be screened regardless of the age of sexual initiation or the presence of other behavior-related risk factors.”

American Cancer Society, American Society for Colposcopy & Cervical Pathology, American Society for Clinical Pathology (Saslow 2012):

“Cervical cancer screening should begin at age 21 years. Women aged younger than 21 years should not be screened regardless of the age of sexual initiation or other risk factors.”

American College of Obstetricians and Gynecologists. 2012. “Practice Bulletin #131 Screening for Cervical Cancer.” Obstet Gynecol. 120:1222-38