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2020 MIPS Measure #425: Photodocumentation of Cecal Intubation

Quality ID


High Priority Measure




Measure Type




Measure Description

The rate of screening and surveillance colonoscopies for which photodocumentation of at least two landmarks of cecal intubation is performed to establish a complete examination



This measure is to be submitted each time a colonoscopy is performed for patients 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.



Patients for whom a screening or surveillance colonoscopy was performed

Denominator Criteria (Eligible Cases):

Patients regardless of age


Patient procedure during the performance period (CPT or HCPCS): 44388, 44389, 44392, 44394, 44404, 45378, 45380, 45381, 45384, 45385, G0105, G0121


Modifier: 73 or 74



Documentation of post-surgical anatomy (e.g., right hemicolectomy, ileocecal resection, etc.): G9613



Number of patients undergoing screening or surveillance colonoscopy who have photodocumentation of at least two landmarks of cecal intubation to establish a complete examination

NUMERATOR NOTE: In the instance that the patient has an anatomical/physiological reason for not capturing photodocumentation of two or more of cecal landmarks (i.e., patient has no cecum), it would be appropriate to submit G9613.

Numerator Options:

Performance Met: Photodocumentation of two or more cecal landmarks to establish a complete examination (G9612)


Performance Not Met: Photodocumentation of less than two cecal landmarks (i.e., no cecal landmarks or only one cecal landmark) to establish a complete examination (G9614)



It is well supported that visualization of the cecum by notation of landmarks and photodocumentation of landmarks should be documented for every colonoscopy. However, one study of administrative claims data (Baxter et al. 2011) and another of 69 hospital-based endoscopists (Cotton et al. 2003) show variable performance among endoscopists in achieving cecal intubation resulting in complete colonic examination.

The American Society for Gastrointestinal Endoscopy (ASGE)/American College of Gastroenterology (ACG) task force on Quality in Endoscopy, specifically in the paper “Quality indicators for colonoscopy”, has recommended documenting cecal intubation as a measure of colonoscopic examination completeness. Based on a study of prevalence of proximal colonic polyps in average-risk asymptomatic patients with negative fecal occult blood tests and flexible sigmoidoscopy (Kadakia et al. 1996), it has been well-established that cecal intubation is required as a marker for examination of the entire colon due to the significant number of neoplasms present in the right colon in the absence of positive fecal occult blood tests or left sided colon neoplasms.

The need for cecal intubation is based on the continual finding that a substantial number of colorectal neoplasms are located in the proximal colon, including the cecum. Numerous studies have shown that physicians routinely do not document the depth of insertion in the colonoscopy report. Quality evaluation of the colon consists of intubation of the entire colon and a detailed mucosal inspection. Cecal intubation improves sensitivity and reduces costs byeliminating the need for radiographic procedures or repeat colonoscopy to complete examination. Careful mucosal inspection is essential to effective colorectal cancer prevention and reduction of cancer mortality.

Clinical Recommendation Statements

As stated in the “Quality indicators for colonoscopy” paper developed by the ASGE/ACG task force on Quality in Endoscopy (Rex et al. 2015), “In the United States, colonoscopy is almost always undertaken with the intent to intubate the cecum. Cecal intubation is defined as passage of the colonoscope tip to a point proximal to the ileocecal valve, so that the entire cecal caput, including the medial wall of the cecum between the ileocecal valve and appendiceal orifice, is visible. Cecal intubation should be documented by naming the identified cecal landmarks. Most importantly, these include the appendiceal orifice and the ileocecal valve.” “The best photographs of the cecum to prove intubation are of the appendiceal orifice, taken from a distance sufficiently far away that the cecal strap fold is visible around the appendix, and a photograph of the cecum taken from distal to the ileocecal valve. It can be helpful to document other landmarks, such as the cecal sling fold or intubation of the terminal ileum.” Due to variations in cecal anatomy, requiring photodocumentation of more than two cecal landmarks is not mandated.

Patients who undergo complete colon examination have a lower risk of colorectal cancer than patients with incomplete colonoscopy as was demonstrated in a study of administrative claims data that found endoscopist quality measures were associated with post colonoscopy colorectal cancer (Baxter et al. 2011). The ASGE/ACG task force on Quality in Endoscopy stated effective colonoscopists should be able to intubate the cecum in ≥ 90% of cases, and in ≥ 95% of cases when the indication is screening in a healthy adult. All colonoscopy studies done for screening have reported cecal intubation rates of 97% or higher.

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