Clinical Quality Measure
CMS140v2 (NQF 0387) - Additional Measure

Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer

Percentage of female patients aged 18 years and older with Stage IC through IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period.

NQS DOMAIN:   Clinical Process/Effectiveness




Description and Implementation within the EMR software

Denominator: All female patients 18 years or older with at least 2 encounters having one of the following ICD-10 codes selected in ASSESSMENT/DIAGNOSIS section on the ENCOUNTER form:
C50.011, C50.012, C50.019, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919, Z85.3

Numerator: Patients in the above mentioned list to whom tamoxifen or aromatase inhibitor was prescribed. UniCharts looks for the custom code QM387A: [Quality Measure] Breast cancer patient with ER or PR positive (3315F), tamoxifen/AI prescribed (4179F) within the PROCEDURES/SERVICES section on the ENCOUNTER form as the required documentation.

Exceptions: UniCharts looks for the custom code QM387E: [Exception] Action specified in CMS140v2 not performed due to medical, patient, or system reasons within the PROCEDURES/SERVICES section on the ENCOUNTER form as the required documentation.

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