CMS130v13 - Colorectal Cancer Screening

Percentage of adults 45-75 years of age who had appropriate screening for colorectal cancer

*Telehealth Eligible*

Numerator

Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria: 

• Fecal occult blood test (FOBT) during the measurement period
• Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period
• Colonoscopy during the measurement period or the nine years prior to the measurement period
• Stool DNA (sDNA) with FIT during the measurement period or the two years prior to the measurement period
• CT Colonography during the measurement period or the four years prior to the measurement period

Colonoscopy is completed during the measurement period or was completed within the nine years prior to the measurement period. Colonoscopies will be counted if they are found in the chart in any of the following ways:

• Clinical Decision Support Rule: The clinician completes the "Colorectal Cancer: Screening" and includes either "colonoscopy completed" or "colonoscopy done" in the Result/Comment section when saving the screening.
• Manually Imported Items: When you import a report of the patient's colonoscopy results, make sure the name of the file includes the word "Colonoscopy"

Fecal occult blood test (FOBT) during the measurement period, identified in any of the following ways:

• Clinical Decision Support Rule: The clinician completes the "Colorectal Cancer: Screening" and includes either of the following phrases when in the Result/Comment section: "fobt completed" "fobt done"
• Electronically received lab: The name of the results should include any of the following phrases:
  • "Occult blood" 
  • "hemoccult"
  • "fecal occult"
• Manually Imported Items: When you import a report of the patient's colonoscopy results, make sure the name of the file includes any of the following phrases:
  • "hemoccult"
  • "fecal occult blood test"
  • "FOBT"

Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period

• Clinical Decision Support Rule: The clinician completes the "Colorectal Cancer: Screening" and includes in the Result/Comment section either of the following phrases: "sigmoidoscopy completed" or "sigmoidoscopy done"
• Manually Imported Items: When you import a report of the patient's colonoscopy results, make sure the name of the file includes the term: "sigmoidoscopy"

Stool DNA (sDNA) with FIT during the measurement period or the two years prior to the measurement period, identified in any of the following ways:

• Clinical Decision Support Rule: The clinician completes the "Colorectal Cancer: Screening" and includes either of the following phrases when in the Result/Comment section:
  • "Stool DNA with FIT done"
  • "Stool DNA with FIT completed"
  • "FIT-DNA completed" 
  • "FIT-DNA done"
  • "Cologuard completed"
  • "Cologuard done"
• Electronically received lab: result from an interface. The name of the results should include any of the following phrases:
  • "Stool DNA with FIT"
  • "sDNA"
  • "FIT-DNA" 
  • "Cologuard"
• Manually Imported Items: When you import a report of the patient's colonoscopy results, make sure the name of the file includes any of the following phrases:
  • "Stool DNA with FIT"
  • "sDNA"
  • "FIT-DNA" 
  • "Cologuard"

CT Colonogaphy during the measurement period or four years prior to the measurement period, identified in any of the following ways:

• Clinical Decision Support Rule: The clinician completes the "Colorectal Cancer: Screening" and includes either of the following phrases when in the Result/Comment section:
  • "CT Colonogaphy completed"
  •  "CT Colonogaphy done"
• Electronically received radiology result: The name of the results should include any of the following phrases:
  • "CT Colon" 
• Manually Imported Items: When you import a report of the patient's colonoscopy results, make sure the name of the file includes any of the following phrases:
  • "CT Colon"

Denominator

Patients 45-75 years of age by the end of the measurement period with a visit during the measurement period

Denominator Exclusions

A patient who meets the criteria to be in the denominator will be excluded from the denominator if they meet either of the following criteria:

• They have had a total colectomy. This would be saved as a text phrase in the Past Medical History field of the patient's chart.
  • "total colectomy"
• The have an appropriate diagnosis of malignant neoplasm of colon on their problem list

• Exclude patients whose hospice or palliative care overlaps the measurement period:
  • Identified in the patient's Alerts and Directives, located in the demographic screen or the Summary Sheet, in the name, text or comments saved with that alert/directive. The Alert/Directive should include either of the following phrases:
    • palliative
    • hospice
• Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period:
  • Accomplished with adding the appropriate billing codes for Domiciliary or rest home visit for evaluation and management. The codes are 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337
• Exclude patients 66 and older by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria:
  • Advanced Illness with two outpatient encounters during the measurement period or the year prior:
    • Identified through a diagnosis in the chart. Note: a diagnosis alone is not enough, the DX code must be added to the assessment and attached to the visit CPT code
  • OR Advanced illness with one inpatient encounter during the measurement period or the year prior
  • Or taking dementia medications during the measurement period or the year prior