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Johns Hopkins Health Plans

CCS-E - Cervical Cancer Screening

Product Lines:
EHP, Priority Partners and USFHP.

Measurement Period: January 1- December 31.

Description:
The percentage of persons 21–64 years of age who were recommended for routine cervical cancer screening and were screened for cervical cancer using any of the following criteria:

  • Persons 21-64 years of age who were recommended for routine cervical cancer screening and had cervical cytology performed within the last 3 years.*
  • Persons 30-64 years of age who were recommended four routine cervical cancer screening and had cervical high-risk human papillomavirus (hrHPV) testing performed within the last five years**.
  • Persons 30-64 years of age who were recommended for routine cervical cancer screening and had cervical cytology/high-risk human papillomavirus (hrHPV) co-testing within the last five years**.

* Three year look back requires 21 years or older on test date.
** Five year look back requires age 30 or older on test date. 

Stratifications: Report stratification by race and ethnicity.

Measure Reporting: HealthChoice Performance Measure reporting for Priority Partners.

Improvement Notation:

Increased score indicates improvement.

Data Collection:

  • ECDS. 

Initial Population:

  • Measure Item Count: Person.
  • Age: 24–64 years of age as of the last day of the measurement period.
  • Gender/sex criteria (persons recommended for routine cervical cancer screening):
    • Administrative Gender of Female (AdministrativeGender code female) any time in the person’s history.
    • Sex Assigned at Birth (LOINC code 76689-9) of Female (Female Value Set) any time in the person’s history.
    • Sex Parameter for Clinical Use of Female (SexParameterForClinicalUse code female-typical) during the measurement period.
  • Benefits: Medical.
  • Continuous Enrollment: The measurement period and the 730 days prior to the measurement period.
  • Allowable Gap: No more than one gap of ≤45 days each year of continuous enrollment. No gaps on the last day of the measurement period.

Denominator:
The initial population minus denominator exclusions.

Numerator:
Persons recommended for routine cervical cancer screening who were screened for cervical cancer. 
Either of the following meets criteria:

  • Persons 24–64 years of age by the last day of the measurement period who were recommended for routine cervical cancer screening and had cervical cytology (Cervical Cytology Lab Test Value Set; Cervical Cytology Result or Finding Value Set) during the measurement period or the 2 years prior to the measurement period.
  • Persons 30–64 years of age by the last day of the measurement period who were recommended for routine cervical cancer screening and had cervical high-risk human papillomavirus (hrHPV) testing (High Risk HPV Lab Test Value Set; SNOMED CT code 718591004) during the measurement period or the 4 years prior to the measurement period, and who were 30 years of age or older on the test date.

Note: Evidence of hrHPV testing within the last 5 years also captures patients who had co-testing; therefore, additional methods to identify co-testing are not necessary.

Best Practice and Measure Tips

  • All tests require date and result.
  • Request results for tests performed by another provider.
  • Complete test during well woman OB/GYN visit, sick visits, urine pregnancy tests, UTI or screening for STDs.
  • Review and document your patient’s surgical and preventive screenings history with results
  • Use correct diagnosis and procedure codes
  • The recommendations apply to all asymptomatic individuals with a cervix, regardless of their sexual history or HPV vaccination status, including those who have undergone supracervical hysterectomy and transgender men who retain their cervix.
    • Transgender and gender diverse patients who have a cervix is recommended to have regular cervical pap tests.

Acceptable:

  • Member reported information documented in the patient’s medical record is acceptable as long as there is a date and result of the test or a date of the hysterectomy and acceptable documentation of no residual cervix. The member reported information must be logged in the patient’s chart by a care provider.
  • Generic documentation of "HPV test" can count as evidence of hrHPV test.
  • Lab results that indicate sample contained "no endocervical cells" may be used if a valid result was reported for test.
  • Lab test wording Ecto/Endo/Vaginal Pool: liquid based
  • Any cervical cancer screening method that includes collection and microscopic analysis of cervical cells.
  • The doctor may document date test done and the result. If date of test stated is “last month,” “last year” etc.
    • Pap Smear/ hrHPV done Jan 20XX-negative – document 1/31/XX
  • HM (Health Maintenance) section of chart if test date and result noted.

Not acceptable:

  • Biopsies or Lab results that indicate inadequate sample or no cervical cells.
  • Biopsies are considered diagnostic and do not meet the measure requirement.
  • Referral to OB/GYN alone does not meet the measure.
  • hrHPV test: DNA reflex test ordered, test not performed.
    • Reflex tests are only completed when the initial Pap test is abnormal.

Measure Exclusions

Denominator Exclusions:

  • Persons receiving palliative care or who had an encounter for palliative care any time during the measurement period.
  • Persons in hospice or using hospice services any time during the measurement period.
  • Persons who died any time during the measurement period.
  • Hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix any time during the member’s history through December 31 of the measurement year.

Acceptable Exclusion:

  • Documentation of a “vaginal Pap smear” with documentation of hysterectomy.
  • Documentation of “vaginal hysterectomy” without further specification.
  • Documentation of hysterectomy and documentation that a member no longer needs Pap testing/cervical cancer screening.
    • Documentation must be from the same provider.
  • Documentation of “complete”, “total” or “radical” hysterectomy (abdominal, vaginal or unspecified) - implies no residual cervix.
  • Documentation of cervical agenesis.

Not Acceptable Exclusions:

  • Documentation of hysterectomy alone does NOT meet the criteria because it does not indicate the cervix has been removed.
  • Supracervical hysterectomy is not acceptable because the cervix remains intact.
  • Check surgical history and physical exam notes. (Documentation of no cervix may be mentioned in the physical portion of the exam).

Exclusion Codes

Absence of Cervix Diagnosis 

  • ICD-10-CM: Q51.5, Z90.710, Z90.712
  • SNOMED CT US Edition: 37687000, 248911005, 428078001, 429290001, 429763009, 473171009, 723171001, 126161000119109, 10738891000119107

Hysterectomy with No Residual Cervix 

  • CPT: 57530, 57531, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58575, 58951, 58953, 58954, 58956, 59135
  • ICD-10-PSC: 
    • [0UTC0ZZ] Resection of Cervix, Open Approach
    • [0UTC4ZZ] Resection of Cervix, Percutaneous Endoscopic Approach
    • [0UTC7ZZ] Resection of Cervix, Via Natural or Artificial Opening
    • [0UTC8ZZ] Resection of Cervix, Via Natural or Artificial Opening Endoscopic
  • SNOMED CT US Edition: 24293001, 27950001, 31545000, 35955002, 41566006, 46226009, 59750000, 86477000, 88144003, 116140006, 116142003, 116143008, 116144002, 176697007, 236888001, 236891001, 287924009, 307771009, 361222003, 361223008, 387626007, 414575003, 440383008, 446446002, 446679008, 608805000, 608806004, 608807008, 708877008, 708878003, 739671004, 739672006, 739673001, 739674007, 740514001, 740515000, 767610009, 767611008, 767612001, 1163275000, 1287897002

Sex Assigned at Birth (LOINC code 76689-9) of Male with:

  • LOINC: LA2-8
  • SNOMED CT US Edition: 248153007
     

Measure Codes

Cervical Cytology Lab Test

  • CPT: 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88164, 88165, 88166, 88167, 88174, 88175
  • HCPCS: G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001
  • LOINC: 104866-9, 10524-7, 18500-9, 19762-4, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5

Cervical Cytology Result or Finding

  • SNOMED CT US Edition: 168406009, 168407000, 168408005, 168410007, 168414003, 168415002, 168416001, 168424006, 250538001, 269957009, 269958004, 269959007, 269960002, 269961003, 269963000, 275805003, 281101005, 309081009, 310841002, 310842009, 416030007, 416032004, 416033009, 439074000, 439776006, 439888000, 441087007, 441088002, 441094005, 441219009, 441667007, 700399008, 700400001, 1155766001, 62051000119105, 62061000119107, 98791000119102

High Risk HPV Tests

  • CPT: 87624, 87625, 87626, 0502U
  • HCPCS: G0476
  • LOINC: 104132-6, 104170-6, 104752-1, 104766-1, 104783-6, 106508-5, 106509-3, 21440-3, 30167-1, 38372-9, 59263-4, 59264-2, 59420-0, 69002-4, 71431-1, 75694-0, 77379-6, 77399-4, 77400-0, 82354-2, 82456-5, 82675-0, 95539-3