CMS 153 - Chlamydia Screening for Women

Overview

CMS153v8 (2020)

CMS153v9 (2021)

CMS153v10 (2022)

Identifiers

CMS eCQM ID NQF eCQM ID NQF MIPS Quality ID
CMS153v10 310

*MIE only supports data collection and reporting using eCQM specifications

Definitions

Description Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period
Initial Patient Population Women 16 to 24 years of age who are sexually active and who had a visit in the measurement period
Denominator Equals Initial Population
Denominator Exclusions
  • Women who are only eligible for the initial population due to a pregnancy test and who had an order for an x-ray or for a specified medication within 7 days of the pregnancy test.
  • Exclude patients who are in hospice care for any part of the measurement period.
Numerator Women with at least one chlamydia test during the measurement period
Numerator Exclusions
Denominator Exceptions

Additional Information

Measure Type Process measure
Measure Scoring Proportion measure
Stratification Stratum 1: Patients age 16-20
Stratum 2: Patients age 21-24
Granularity Patient
Improvement Notation Higher score indicates better quality
Domain Community/Population Health

Clinical Instructions

New UI Visit Encounter (valid RC202109+)

Original Visit Encounter

Ensure all sexually active women aged 16-24 are screened for chlamydia at least once within the measurement period. Use either the Test and Procedures section of the encounter, or enter the appropriate observation to the chart using the Observations chart tab.

Tip
Regardless of how the chlamydia screening observation is added to the chart, clients will need to ensure the appropriate observation is configured with the required LOINC. Clients should search the Observation Codes editor for the chlamydia observations to determine if multiple observations need to be merged.
  1. While documenting the Visit encounter, document the results of a chlamydia screening one of two ways:
  2. Option 1: Tests and Procedures Section
    1. Open the Tests and Procedures section.
    2. Using the autocomplete, begin typing Chlamydia, and select the appropriate screening.
    3. Click the Add to Exam button.
    4. After adding the new section, open the screening section and enter the results.
    5. Click the Next button, or close the section.
  3. Option 2: Add Observation using Observations Chart Tab
    1. Navigate to the patient chart.
    2. Open the Observations tab of the Medical Records chart tab.
    3. Click the Add Observation link in the upper-right corner.
    4. Begin typing the name of the observation and select the appropriate one.
    5. Enter the Date the screening was performed, its Result, and any relevant Comments.
    6. Click the Submit button.
  4. Continue documenting the encounter, as needed.
  5. When completed, Close and Archive the encounter

Evidence

Initial Patient Population

Name Value Set
Assessment, Performed: Sexually Active 2.16.840.1.113883.3.464.1003.121.12.1040
Diagnosis: Complications of Pregnancy, Childbirth and the Puerperium 2.16.840.1.113883.3.464.1003.111.12.1012
Diagnosis: Diagnoses Used to Indicate Sexual Activity 2.16.840.1.113883.3.464.1003.111.12.1018
Diagnosis: HIV 2.16.840.1.113883.3.464.1003.120.12.1003
Diagnostic Study, Order: Diagnostic Studies During Pregnancy 2.16.840.1.113883.3.464.1003.111.12.1008
Encounter, Performed: Home Healthcare Services 2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed: Office Visit 2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed: Online Assessments 2.16.840.1.113883.3.464.1003.101.12.1089
Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up 2.16.840.1.113883.3.464.1003.101.12.1025
Encounter, Performed: Preventive Care Services, Initial Office Visit, 0 to 17 2.16.840.1.113883.3.464.1003.101.12.1022
Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up 2.16.840.1.113883.3.464.1003.101.12.1023
Encounter, Performed: Preventive Care, Established Office Visit, 0 to 17 2.16.840.1.113883.3.464.1003.101.12.1024
Encounter, Performed: Telephone Visits 2.16.840.1.113883.3.464.1003.101.12.1080
Laboratory Test, Order: Lab Tests During Pregnancy 2.16.840.1.113883.3.464.1003.111.12.1007
Laboratory Test, Order: Lab Tests for Sexually Transmitted Infections 2.16.840.1.113883.3.464.1003.110.12.1051
Laboratory Test, Order: Pap Test 2.16.840.1.113883.3.464.1003.108.12.1017
Laboratory Test, Order: Pregnancy Test 2.16.840.1.113883.3.464.1003.111.12.1011
Medication, Active: Contraceptive Medications 2.16.840.1.113883.3.464.1003.196.12.1080
Medication, Order: Contraceptive Medications 2.16.840.1.113883.3.464.1003.196.12.1080)
Medication, Order: Isotretinoin 2.16.840.1.113883.3.464.1003.196.12.1143
Procedure, Performed: Procedures Used to Indicate Sexual Activity 2.16.840.1.113883.3.464.1003.111.12.1017

Denominator Exclusions

Name Value Set
Diagnostic Study, Order: X-Ray Study (all inclusive) 2.16.840.1.113883.3.464.1003.198.12.1034
Encounter, Performed: Encounter Inpatient 2.16.840.1.113883.3.666.5.307
Intervention, Order: Hospice care ambulatory 2.16.840.1.113762.1.4.1108.15
Intervention, Performed: Hospice care ambulatory 2.16.840.1.113762.1.4.1108.15

Numerator

Name Value Set
Laboratory Test, Performed: Chlamydia Screening 2.16.840.1.113883.3.464.1003.110.12.1052

Source(s)

eCQI CMS153


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