This document details the methodology for the Screening/Surveillance Colonoscopy measure and should be reviewed along with the Screening/Surveillance Colonoscopy Measure Codes List file, which contains the medical codes used in constructing the measure.
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures.
The Screening/Surveillance Colonoscopy episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo a screening or surveillance colonoscopy procedure during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 14 days after the trigger
Screening colonoscopy has become the most common screening test for colorectal cancer in the US, and the colorectal cancer screening guidelines released by the United States Preventive Services Task force recommend either a screening colonoscopy every 10 years or other screening methods for adults aged 50 – 75 who are at average risk for developing colorectal cancer.3 The Screening/Surveillance Colonoscopy episode-based cost measure was recommended for development by an expert clinician committee—the Gastrointestinal Disease Management - Medical and Surgical Clinical Subcommittee—because of its high impact in terms of patient population and Medicare spending, and the opportunity for incentivizing costeffective, high-quality clinical care in this area. Subsequently, members of the Clinical Subcommittee provided extensive, detailed input on this measure
The cost measure numerator is the sum of the ratio of observed to expected4 paymentstandardized cost to Medicare for all Screening/Surveillance Colonoscopy episodes attributed to a clinician. This sum is then multiplied by the national average observed episode cost to generate a dollar figure.
The cost measure denominator is the total number of episodes from the Screening/Surveillance Colonoscopy episode group attributed to a clinician.
The Screening/Surveillance Colonoscopy cost measure uses the following data sources:
- Medicare Parts A and B claims data from the Common Working File (CWF)
- Enrollment Data Base (EDB)
- Long Term Care Minimum Data Set (LTC MDS)5
Methodologically, the Screening/Surveillance Colonoscopy cost measure can be triggered based on claims data from the following settings: ambulatory surgical centers (ASC), ambulatory/office-based care, and hospital outpatient department (HOPD).
The cohort for this cost measure consists of patients who are Medicare beneficiaries enrolled in Medicare fee-for-service and who undergo a screening or surveillance colonoscopy procedure that triggers a Screening/Surveillance Colonoscopy episode.
The cohort for this cost measure is also further refined by the definition of the episode group and measure-specific exclusions (see Appendix A).
1 - Claim payments are standardized to account for differences in Medicare payments for the same service(s) across Medicare providers. Payment standardized costs remove the effect of differences in Medicare payment among health care providers that are the result of differences in regional health care provider expenses measured by hospital wage indexes and geographic price cost indexes (GPCIs) or other payment adjustments such as those for teaching hospitals. For more information, please refer to the “CMS Price (Payment) Standardization - Basics" and “CMS Price (Payment) Standardization - Detailed Methods” documents posted on the Payment Standardization QualityNet webpage. (https://www.qualitynet.org/inpatient/measures/payment-standardization)
2 - Cost is defined by allowed amounts on Medicare claims data, which include both Medicare trust fund payments and any applicable beneficiary deductible and coinsurance amounts. Claims data from Medicare Parts A and B are used to construct the episode-based cost measures.
3 - Bibbins-Domingo, K., D. C. Grossman, S.J. Curry, K. W. Davidson, J. W. Epling, Jr., F. A. Garcia, M. W. Gillman, et al. “Screening for Colorectal Cancer: Us Preventive Services Task Force Recommendation Statement.” [In eng]. JAMA 315, no. 23 (Jun 21, 2016): 2564-75.
4 - Expected costs refer to costs predicted by the risk adjustment model. For more information on expected costs and risk adjustment, please refer to Section A.5.
5 - For information on how LTC MDS data are used in risk adjustment, please refer to Section A.5.