Measure Description
Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy.
Instructions
This measure is to be submitted each time a surveillance colonoscopy is performed during the performance period. It is anticipated the Merit-based Incentive Payment System (MIPS) eligible clinician who performs the listed procedures, as specified in the denominator coding, will submit on this measure. Patients who have a coded colonoscopy procedure that has a modifier 52, 53, 73 or 74 will not qualify for inclusion into this measure.
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
All patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings
Denominator Instructions:
MIPS eligible clinicians who indicate that the colonoscopy procedure is incomplete or was discontinued should use the procedure number and the addition (as appropriate) of modifier 52, 53, 73, or 74. Patients who have a coded colonoscopy procedure that has a modifier 52, 53, 73, or 74 will not qualify for inclusion into this measure.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for history of adenomatous (colonic) polyp(s) (ICD-10-CM): Z86.010
AND
Patient procedure during the performance period (CPT or HCPCS): 44388, 44389, 44392, 44394, 45378, 45380, 45381, 45384, 45385, G0105
WITHOUT
Modifiers: 52, 53, 73 or 74
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02
Numerator
Patients who had an interval of 3 or more years since their last colonoscopy
Numerator Options:
Performance Met: Interval of 3 or more years since patient’s last colonoscopy, documented (0529F)
OR
Denominator Exception: Documentation of medical reason(s) for an interval of less than 3 years since the last colonoscopy (e.g., last colonoscopy incomplete, last colonoscopy had inadequate prep, piecemeal removal of adenomas, last colonoscopy found greater than 10 adenomas, or patient at high risk for colon cancer [Crohn’s disease, ulcerative colitis, lower gastrointestinal bleeding, personal or family history of colon cancer, hereditary colorectal cancer syndromes]) (G9998)
OR
Denominator Exception: Documentation of system reason(s) for an interval of less than 3 years since the last colonoscopy (e.g., unable to locate previous colonoscopy report, previous colonoscopy report was incomplete) (G9999)
OR
Performance Not Met: Interval of less than 3 years since patient’s last colonoscopy, reason not otherwise specified (0529F with 8P)
Rationale
Colorectal cancer is the 2nd leading cause of cancer-related death in the United States. Colonoscopy is the recommended method of surveillance after the removal of adenomatous polyps because it has been shown to significantly reduce subsequent colorectal cancer incidence. The time interval for the development of malignant changes in adenomatous polyps is estimated at 5 to 25 years. (ICSI, 2006) Inappropriate interval recommendations can result in overuse of resources and can lead to significant patient harm. Performing colonoscopy too often not only increases patients’ exposure to procedural harm, but also drains resources that could be more effectively used to adequately screen those in need. (Lieberman et al, 2009)
Clinical Recommendation Statements
Patients with only 1 or 2 small (< 1 cm) tubular adenomas with only low-grade dysplasia should have their next follow- up colonoscopy in 7–10 years. Patients who underwent colonoscopy prior to 2020 and were noted to have only 1 or 2 small (< 1 cm) adenomas may undergo subsequent colonoscopy in 5-10 years based on earlier U.S. Multi-Society Task Force (USMSTF) guidelines; the precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings, family history, and the preferences of the patient and judgment of the physician). (Gupta et al. 2020). Patients with 3-4 tubular adenomas < 1cm in size are recommended to undergo follow-up colonoscopy in 3-5 years. Patients with 5 to 10 adenomas, or any adenoma ≥ 1 cm, or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years. These recommendations assume that piecemeal removal has not been performed and the adenoma(s) are removed completely during the initial colonoscopy. If the initial colonoscopy showed 1-4 adenomas < 1 cm in size and follow-up colonoscopy is normal, then the interval for the subsequent examination should be 10 years. If the initial colonoscopy showed 5-10 adenomas, an adenoma ≥1 cm, or an adenoma with high grade dysplasia or villous features and follow-up colonoscopy is normal, then the interval for the subsequent examination should be 5 years (Gupta et al. 2020).
Patients with > 10 adenomas are thought to be at particularly high risk, and current USMSTF guidelines recommend early surveillance colonoscopy, in 1 year, for these individuals. (Gupta et al. 2020). However, it is important to note that risk is a continuum; an individual with 11 adenomas is not at dramatically higher risk than an individual with 9 or 10 adenomas. Thus, the optimal threshold at which early surveillance colonoscopy becomes worthwhile is subject to debate. For instance, in the United Kingdom, early surveillance colonoscopy is recommended for individuals with even fewer adenomas (≥ 5 adenomas of any size, or ≥ 3 adenomas with at least one large adenoma). A lower threshold is likely to result in higher colonoscopy utilization, but it may also provide greater clinical benefit. (Martinez, et al, 2012).