[CMS130v12] Colorectal Cancer Screening

Contents

• Measure Details
• Measure Parameters
• Elation Workflows
• Measure Information
• Attachments

 

 

Measure Details

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

 

Measure Parameters

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
• FIT-DNA 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

Denominator: Patients 46-75 years of age by the end of the measurement period with a visit during the measurement period.

Exclusions/Exceptions:

• Exclude patients who are in hospice care for any part of the measurement period.
• Exclude patients with a diagnosis or past history of total colectomy or colorectal cancer.
• Exclude patients receiving palliative care during the measurement period.
• 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.
• 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 criteria advanced illness criteria:
  • Advanced illness with two outpatient encounters during the measurement period or the year prior
  • OR advanced illness with one inpatient encounter during the measurement period or the year prior
  • OR taking dementia medications for any part of the measurement period or the year prior

These are the exclusion document tags for this measure (Reference: Tag Reports and Notes with Document Tags):

• EXCLUSION: HOSPICE CARE
• EXCLUSION: IP DISCHARGE STATUS TO HEALTH CARE FACILITY FOR HOSPICE CARE
• EXCLUSION: IP DISCHARGE STATUS TO HOME FOR HOSPICE CARE
• EXCLUSION: COLECTOMY NO COL SCRN 

How to document frailty:

To document frailty in Elation, both conditions below have to be met:

1. add a frailty diagnosis to the patient's Problem List
2. meet one of the following criteria:
   1. record an advanced illness diagnosis in 2 outpatient encounters
   2. record an advanced illness in 1 inpatient counter
   3. record a dementia medication in the patient's chart

You can also document the use of a frailty device to claim the first part of the exclusion. To do so, please add a document tag that represents the frailty device to a visit note from the reporting year. The document tag should have the device code and description and can be created directly in the visit note or within your Document Tags Settings page in Elation. Attachments with device codes are also in the Attachments section of this article.


 

 

Elation Workflows

1. Documenting a screening from a visit note:

   • Elation's Clinical Reminders Feature allows you to easily document screenings. When a patient is due for a Colorectal Cancer Screening, an alert will report at the top of the patient's visit note. Options for selecting the measure will appear after clicking address:

2. Documenting a screening from the patient chart:
   1. For a patient in the denominator, scroll to the bottom of their clinical profile, where their Health Maintenance items appear.
   2. Click on Colorectal Screening, indicate the date of the patient’s most recent Colorectal Screening (FOBT, Colonoscopy, Flexible sigmoidoscopy, FIT DNA, or CT Colonography), and click "Save New".

3. Tag a report in the patient’s record with one of the following document tags. This alone will meet the health maintenance requirement (Reference: Tag Reports and Notes with Document Tags):
   • COLONOSCOPY (RESULT: NEGATIVE)
   • COLONOSCOPY (RESULT: POSITIVE)
   • FIT DNA (RESULT: NEGATIVE)
   • FIT DNA (RESULT: POSITIVE) 
   • FLEXIBLE SIGMOIDOSCOPY (RESULT: NEGATIVE)
   • FLEXIBLE SIGMOIDOSCOPY (RESULT: POSITIVE)
   • FOBT (RESULT: NEGATIVE) 
   • FOBT (RESULT: POSITIVE) 
   • CT COLONOGRAPHY (RESULT: NEGATIVE)
   • CT COLONOGRAPHY (RESULT: POSITIVE) 

 

Measure Information

Colorectal cancer represents eight percent of all new cancer cases in the United States. In 2020, there were an estimated 147,950 new cases of colorectal cancer and an estimated 53,200 deaths attributed to it. According to the National Cancer Institute, about 4.2 percent of men and women will be diagnosed with colorectal cancer at some point during their lifetimes. For most adults, older age is the most important risk factor for colorectal cancer, although being male and black are also associated with higher incidence and mortality. Colorectal cancer is most frequently diagnosed among people 65 to 74 years old (National Cancer Institute, 2020).
 

Screening can be effective for finding precancerous lesions (polyps) that could later become malignant, and for detecting early cancers that can be more easily and effectively treated. Precancerous polyps usually take about 10 to 15 years to develop into colorectal cancer, and most can be found and removed before turning into cancer. The five-year relative survival rate for people whose colorectal cancer is found in the early stage before it has spread is about 90 percent (American Cancer Society, 2020).

Reference: Measure Information from CMS


 

Attachments

• Advanced Illness Codes
• Frailty Codes
• Frailty Descriptions

 

Related Articles

• MIPS (2024)- Quality Category
• Clinical Quality Measures Reports Guide
• Clinical Reminders for Clinical Quality Measures
• Tag Reports and Notes with Document Tags
• Health Maintenance Documentation and Reminders
• MIPS (2024) Overview
• MIPS (2024)- Quick Start Guide