URSA-MSSP-CQM-BCS-PR: Breast Cancer Screening CQM (Q112 CQM PR)

  • Published on Feb 4, 2026
  • 2 minute(s) read
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Measure Description

Among women 40 to 74 years of age with a prior qualifying visit in the last 12 months and data completeness for the prior 12 months, the percentage with a mammogram to screen for breast cancer in the prior 27 months.

Metadata

  • Measure Identifier: URSA-MSSP-CQM-BCS-PR
  • Measure Type: Rate Measure
  • Temporal Structure: Entity
  • Component Class: Normal-Form
  • Denominator Case Field: Patient ID
  • Target Direction: Up

Denominator Description

Women 40-74 years of age with a prior qualifying visit in the last 12 months and data completeness.

Numerator Description

Patients with qualifying denominator patients with one or more mammograms in the 27 months prior to the snapshot date.

Published Fields

  • Data Model Keys

    • Patient ID
    • Primary Payor ID
    • Primary Plan ID
    • Primary Plan Attributee Provider ID
    • Primary Plan Attributee Provider Contract ID

  • Metadata Fields

    • Measure ID
    • Measure Name
    • Table Last Updated Datetime

  • Operations Support Fields

    • Affiliated Program Entity ID
    • Affiliated Program Entity Provider ID
    • Program Entity Operational ID
    • Program Operational ID
    • Is Patient Affiliated to a Program Entity

  • Date Fields

    • Snapshot Date -- The date, evaluated at 00:00:00 AM, giving the moment the state of the world will be set to for the purposes of an analysis. The snapshot date does not represent the freshness of the data, or the date in real time at which an analysis was executed.
    • Current Continuous Primary Payor Membership Episode Start Date
    • Current Continuous Primary Payor Membership Episode End Date
    • Segment Start Date -- The start date of the reporting segment. (See also [URSA-CORE] Reporting Segment)
    • Segment End Date -- The end date of the reporting segment. (See also [URSA-CORE] Reporting Segment)

  • Patient Fields

    • Patient Operational ID
    • Member MBI
    • Patient Date of Birth
    • Patient Age at Beginning of Performance Period
    • Is Patient Sex Male
    • Is Patient Sex Female
    • Patient State Abbreviation
    • Patient ZIP Code 5-Digit

  • Insurance Fields

    • Primary Payor Description
    • Primary Plan Description
    • Primary Plan Financial Class Description

  • Provider Fields

    • Primary Plan Attributee Provider Description
    • Affiliated Program Entity Provider NPI
    • Affiliated Program Entity Provider Description

  • Denominator Fields

    • Is Denominator Event Criterion Met
    • Qualifying Denominator Encounter Date
    • Qualifying Denominator Encounter Provider ID
    • Qualifying Denominator Encounter Provider Description
    • Is Data Completeness Continuous Membership Criterion Met
    • Is Any Required Exclusion
    • Is Required Exclusion for Bilateral Mastectomy
    • Is Required Exclusion for Hospice
    • Is Required Exclusion for 66+ with Institutional Special Needs Plan
    • Is Required Exclusion for 66+ with Frailty and Dementia Medications
    • Is Required Exclusion for 66+ with Frailty and Advanced Illness
    • Is Eligible Population
    • Denominator Excluded Reasons Description

  • Numerator Fields

    • Numerator Component Contribution
    • Numerator Document ID
    • Numerator Document Effective Date
    • Numerator Category Description
    • Numerator HCPCS Code
    • Numerator HCPCS Description
    • Numerator Source ID
    • Is Numerator Qualifying Using Standard End-of-Year Timing
    • Numerator Component Contribution Using Standard End-of-Year Timing

  • Measure Fields

    • Denominator