Measure Description
The percentage of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy
Instructions
This measure is to be submitted each time a screening colonoscopy for colorectal cancer is performed during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
Measure Submission Type
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
Denominator
Patients age 50 years or older undergoing a screening colonoscopy
Definition:
Colorectal Cancer Precursor Lesions – Based on pathologic diagnosis, colorectal cancer precursor lesions include: adenomatous polyps [high-grade dysplasia, tubular, tubulovillous, villous] and traditional serrated adenomas, sessile serrated polyps and sessile serrated adenomas.
Screening Colonoscopy Exams – For purposes of this measure, the primary indication of a colonoscopy is screening when the procedure is performed to detect polyps/lesions in the absence of signs, symptoms, or personal history of colon neoplasia, even if during the screening colonoscopy polyps are found, removed or biopsied. If the primary indication for performing the colonoscopy is diagnostic or surveillance then the patient would not meet the intent of the measure.
Diagnostic Colonoscopy Exams – For purposes of this measure, the primary indication of a colonoscopy is diagnostic if the procedure is performed on a patient for the purpose of evaluating past and/or present gastrointestinal symptoms, polyps, GI disease, iron-deficiency anemia, and/or any other abnormal tests (e.g., positive fecal occult blood, abnormal radiographic/imaging studies, or abnormal genetic material).
Surveillance Colonoscopy Exams (i.e., Patients with Personal History of Colonic Polyps, Colon Cancer, or Other Malignant Neoplasm of Rectum, Rectosigmoid Junction, and Anus) – A surveillance colonoscopy can be performed at varying ages and intervals based on the patient's personal history of colon cancer, polyps, and/or gastrointestinal disease. Colonoscopy for patients with a history of colon polyp(s) is identified as a surveillance colonoscopy rather than a screening colonoscopy. The following codes are included in the Denominator Exclusion (G9936) to assist with identifying a personal polyp history: Z85.038, Z85.048, Z86.010
DENOMINATOR NOTE: The intention of the measure is to identify patients with an adenoma(s) or colorectal cancer detected during a screening colonoscopy. A patient with a family history of colon neoplasia, but no personal history of colon neoplasm would be eligible for the denominator criteria population for this measure. Patients with a personal history of colon neoplasia, colonic polyps, colon cancer, or other malignant neoplasm of the rectum, rectosigmoid junction or anus would not be eligible for denominator and would qualify for the Denominator Exclusion code G9936. In order to submit the Denominator Exclusion code G9937, the primary indication for the colonoscopy exam would be a diagnostic indication (i.e., a colonoscopy performed on a patient who has past and/or present gastrointestinal symptoms, polyps, GI disease, iron-deficiency anemia, and/or any other abnormal tests).
Denominator Criteria (Eligible Cases):
Patients 50 years of age or older on date of encounter
AND
Risk factors for colorectal cancer (ICD-10-CM): Z80.0, Z83.71, Z12.11
AND
Patient procedure during performance period (CPT or HCPCS): 45378, 45380, 45381, 45384, 45385, G0121
WITHOUT
Modifiers: 52, 53, 73, or 74
AND NOT
DENOMINATOR EXCLUSIONs:
Surveillance colonoscopy – Personal history of colonic polyps, colon cancer, or other malignant neoplasm of rectum, rectosigmoid junction, and anus: G9936
OR
Diagnostic colonoscopy: G9937
Numerator
Number of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy
Numerator Options:
Performance Met: Adenoma(s) or colorectal cancer detected during screening colonoscopy (G9933)
OR
Denominator Exception: Documentation that neoplasm detected is only diagnosed as traditional serrated adenoma, sessile serrated polyp, or sessile serrated adenoma (G9934)
OR
Performance Not Met: Adenoma(s) or colorectal cancer not detected during screening colonoscopy (G9935)