eCQM: Colorectal Cancer Screening (CMS 130v5)

eCQM:

Colorectal Cancer Screening

CMS ID:

CMS 130v5

NQF Number:

0034

NQS Domain:

Effective Clinical Care

Measure Type:

Process

MIPS High Priority Measure:

No

Eligible for Quality Programs:

  • Merit-Based Incentive Payment System (MIPS)
  • Medicaid EHR Incentive Program (Meaningful Use)
  • Comprehensive Primary Care Plus (CPC+)

Description:

Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer.

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

    • 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.

  • Denominator: Patients 50-75 years of age with an eligible visit (defined as a chart note with one of the following encounter types: Office Visit, Home Visit, Nurse Visit, Nursing Home Visit) during the measurement period.

    • Denominator Exclusions: Patients with a diagnosis or past history of total colectomy or colorectal cancer.

    • Denominator Exceptions: None

Performance Benchmark for MIPS: 82.29%
For further benchmarks and details on how this measure will be scored within the Quality performance category of MIPS, please click here.

Practice Fusion Suggested Workflow
Practice Fusion suggests the following workflow to help ensure that you are able to meet the requirements of this measure within the Practice Fusion EHR.

  1. Determine that the patient falls within the denominator eligible age range for the measure (50-75 years of age).

  2. Complete one of the following:

    1. Receive or record structured lab results for a Fecal Occult Blood Test in the Practice Fusion EHR using the suggested workflow in Table 1.

    2. Perform and/or document a flexible sigmoidoscopy using the Practice Fusion suggested workflow in Table 1.

    3. Perform and/or document a colonoscopy using the Practice Fusion suggested workflow in Table 1.

Table 1. Numerator Suggested Workflows for CMS 130v5

Procedure Type

Practice Fusion Suggested Workflow

Fecal Occult Blood Test (FOBT) Codes

  • FOBT LOINC codes will be included in this measure when they are associated with structured lab results.

  • The codes listed below will meet the measure criteria when manually recording structured lab results in the EHR or when receiving structured lab results from connected labs:

    • Hemoglobin, gastrointestinal [Presence] in Stool (LOINC 2335-8)

    • Hemoglobin, gastrointestinal [Presence] in Stool - 1st specimen (LOINC 14563-1)

    • Hemoglobin, gastrointestinal [Presence] in Stool by Immunologic method (LOINC 29771-3)

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

  • In the Screenings/Interventions/Assessments section of the encounter, search for a flexible sigmoidoscopy and select the item. Qualifying procedures are as follows:

    • Flexible fiberoptic sigmoidoscopy (procedure) (SNOMED CT 44441009)

    • Flexible fiberoptic sigmoidoscopy for removal of foreign body (procedure) (SNOMED CT 112870002)

    • Flexible fiberoptic sigmoidoscopy with biopsy (procedure) (SNOMED CT 396226005)

    • Diagnostic endoscopic examination of lower bowel and sampling for bacterial overgrowth using fiberoptic sigmoidoscope (procedure) (SNOMED CT 425634007)

  • Record and save the following information in the modal window that opens:

    • Status: Performed

    • Start Date: Date the procedure was performed

Colonoscopy
(during the measurement period or the nine years prior to the measurement period)

  • In the Screenings/Interventions/Assessments section of the encounter, search for the applicable colonoscopy that was performed and select the item. Examples include:

    • Open colonoscopy (procedure) (SNOMED CT 174158000)

    • Total colonoscopy (procedure) (SNOMED CT 235150006)

    • Fiberoptic colonoscopy with biopsy (procedure) (SNOMED CT 25732003)

  • Record and save the following information in the modal window that opens:

    • Status: Performed

    • Start Date: Date the procedure was performed

Note: Only procedures that occur during the appropriate time frame listed for each screening will result in numerator credit.

Additional Measure Information

  • This 2016 measure version has been updated from the previous 2015 version specifications, incorporating the following change:

    • Removed the word “below” from the measure description because it is redundant.

  • To be recognized for the denominator exclusion, the patient must have a Total Colectomy procedure or diagnosis of Malignant Neoplasm of Colon recorded in his or her chart. The suggested workflow detailed in Table 2 below can be used to record the appropriate data for the patient.

  • To access a complete list of qualifying procedures and test codes, visit the United States Health Information Knowledgebase (USHIK). This site is produced by the Agency for Healthcare Research and Quality (AHRQ) in partnership with CMS and the National Library of Medicine (NLM). A free Unified Medical Language System® (UMLS) license, available from NLM, is required to access USHIK.

Table 2. Suggested Workflow for CMS130v5 Denominator Exclusions

Reason for exclusion

Practice Fusion Suggested Workflow

Total Colectomy
(procedure)

  • In the Screenings/Interventions/Assessments section of the encounter, search for a total colectomy. Examples include:

    • Total colectomy (procedure) (SNOMED CT 26390003)

    • Restorative proctocolectomy (procedure) (SNOMED CT 235331003)

    • Total abdominal colectomy with ileoproctostomy (procedure) (SNOMED CT 36192008)

  • Record and save the following information in the modal window that opens:

    • Status: Performed

    • Start Date: Date the procedure was performed

Malignant Neoplasm of Colon
(diagnosis)

  • In the patient encounter, use the Diagnosis OR Assessment section of the chart note to record a diagnosis for Malignant Neoplasm of Colon. Example diagnoses include:

    • Malignant neoplasm of cecum (ICD-10 C18.0)

    • Malignant neoplasm of appendix (ICD-10 C18.1)

    • Malignant neoplasm of transverse colon (ICD-10 C18.4)

  • Add a start date for the diagnosis before saving to the encounter.

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