Product Lines: Advantage MD.

Measurement Period: January 1–December 31.

Description:
For persons 65 years of age and older, the risk-adjusted ratio of observed-to-expected unplanned acute hospitalizations (inpatient and observation stays) for any diagnosis that occurred within 15 days following select outpatient colonoscopies.

Data Collection:

• Administrative.

Note: Supplemental data may only be used for the hospice exclusion.

Initial Population:

• Measure Item Count: Episode.
• Age: Persons 65 years of age and older as of the outpatient general surgery episode date.
• Gender/Sex Criteria: Female, Male
• Benefits: Medical.
• Continuous Enrollment: 365 days prior to the outpatient colonoscopy episode date through 15 days after the episode date.
• Allowable gap:
  • 365 days prior to the outpatient colonoscopy episode: No more than one gap of <45 days.
  • Outpatient colonoscopy episode through 15 days after the episode: No gaps.

Definition:
Direct transfer: A direct transfer occurs when the discharge date from an initial stay is followed by an admission to a subsequent stay within one calendar day or less. Direct transfers can occur between different facilities and between acute inpatient and observation settings.

Outpatient colonoscopy episode: An eligible outpatient colonoscopy performed between January 1 and December 16 of the measurement period, as specified in the denominator criteria.

Outpatient colonoscopy episode date: The service date for a qualifying outpatient colonoscopy episode is defined as the date the procedure occurred. If the episode extends over multiple calendar days, the final date of service should be used as the episode date.

Planned hospital stay: A hospital stay that meets criteria of the numerator exclusion.

Denominator:
Outpatient colonoscopy episodes (Routine Colonoscopy with Ambulatory Surgery POS) between January 1 and December 16 of the MY.

Note: The measure is based on episodes; therefore, it is possible for the denominator to include multiple events for the same person.

Numerator:
Acute hospitalization within 2 and 15 days of the outpatient colonoscopy episode.

Best Practice and Measure Tips

• New Measure for HEDIS MY 2026.
• This measure helps identify complications or poor-quality outcomes after outpatient colonoscopies, supporting quality improvement efforts in ambulatory surgical centers (ASCs) and outpatient settings.
• Ensure accurate documentation of colonoscopy procedures and discharge dates.
• Monitor post-procedure complications like bleeding or perforation.
• Educate patients on symptoms that warrant urgent care.
• Coordinate follow-up care to reduce unnecessary hospital visits.

Ensure Accurate and Complete Claims Documentation for Risk Adjustment Integrity

Why it matters: The HFC measure uses claims-based diagnoses only to calculate risk adjustment scores. This means that any missing or inaccurate diagnosis coding can distort the expected hospitalization rate and negatively impact performance.

Actionable steps for providers:

• Thoroughly document all relevant comorbidities during patient visits, especially chronic and high-risk conditions that influence hospitalization risk.
• Document observation stays clearly, including clinical rationale and service dates.
• Use specific and complete ICD-10 codes—avoid unspecified or vague diagnoses.
• Ensure diagnoses reflect the patient’s condition at the time of service, not just historical data.
• Collaborate with clinical teams to clarify documentation gaps that affect coding accuracy.
• Ensure timely claim submission to avoid missing the measurement window.
• Do not rely on supplemental data to improve risk scores, as only diagnoses captured through claims are considered valid.
• Perform routine audits of diagnosis coding and claim completeness.
• When documenting patient transfers:
  • Record transfers between facilities as separate admissions.
  • Clearly indicate changes in service level within the same institution (e.g., ICU to step-down unit) to ensure accurate classification.
  • Differentiate service categories such as acute vs. nonacute or mental health vs. non-mental health services when applicable.

By focusing on precise documentation and claims integrity, providers can help ensure fair risk adjustment and better reflect the complexity of their patient population.

Measure Exclusions

Denominator Exclusions:

Exclude outpatient colonoscopy episodes that meet any of the following criteria:

• Persons in hospice or using hospice services any time during the measurement period.
• Occurs the day (1) before an inpatient stay or observation stay admission date or at any time during an inpatient or observation stay.
• Occurs concurrently (on the same claim) with a high-risk GI endoscopy procedure.
• Followed by a subsequent outpatient colonoscopy (Routine Colonoscopy Value Set with Ambulatory Surgery POS Value Set) within 15 days following the episode date.
• History or current diagnosis of irritable bowel diseases 365 days prior to the outpatient colonoscopy episode date through 15 days after the episode date.

Numerator Exclusions:

Acute hospitalization within 15 days of the outpatient colonoscopy episode excludes inpatient and observation stay discharges with any of the following criteria on the discharge claim:

• Nonacute inpatient stays
• A principal diagnosis of a malignant neoplasm.
• A planned hospital stay using any of the following:
  • A principal diagnosis of maintenance chemotherapy.
  • A principal diagnosis of rehabilitation.
  • An organ transplant.
  • A potentially planned procedure without a principal acute diagnosis.

Exclusion Codes

Nonacute Inpatient Stay

• UREV: 0022, 0024, 0118, 0128, 0138, 0148, 0158, 0190, 0191, 0192, 0193, 0194, 0199, 0524, 0525, 0550, 0551, 0552, 0559, 0660, 0661, 0662, 0663, 0669, 1000, 1001, 1002
• UBTOB (Type of Bill codes): 0180, 0181, 0182, 0183, 0184, 0185, 0187, 0188, 0210, 0211, 0212, 0213, 0214, 0215, 0217, 0218, 0220, 0221, 0222, 0223, 0224, 0225, 0227, 0228, 0280, 0281, 0282, 0283, 0284, 0285, 0287, 0288, 0289, 0650, 0651, 0652, 0653, 0654, 0655, 0657, 0658, 0660, 0661, 0662, 0663, 0664, 0665, 0667, 0668, 0860, 0861, 0862, 0863, 0864, 0865, 0867, 0868, 018F, 018G, 018H, 018I, 018J, 018K, 018M, 018O, 018X, 018Y, 018Z, 021F, 021G, 021H, 021I, 021J, 021K, 021M, 021O, 021X, 021Y, 021Z, 022F, 022G, 022H, 022I, 022J, 022K, 022M, 022O, 022X, 022Y, 022Z, 028F, 028G, 028H, 028I, 028J, 028K, 028M, 028O, 028X, 028Y, 028Z, 065F, 065G, 065H, 065I, 065J, 065K, 065M, 065O, 065X, 065Y, 065Z, 066F, 066G, 066H, 066I, 066J, 066K, 066M, 066O, 066X, 066Y, 066Z, 086F, 086G, 086H, 086I, 086J, 086K, 086M, 086O, 086X, 086Y, 086Z

High Risk Upper GI Endoscopy:

• CPT: 43180, 43204, 43205, 43210, 43212, 43215, 43216, 43217, 43227, 43229, 43231, 43232, 43237, 43238, 43240, 43241, 43242, 43243, 43244, 43245, 43246, 43247, 43250, 43251, 43255, 43257, 43259, 43266, 43270, 44150, 44151, 44155, 44156, 44157, 44158, 44210, 44211, 44212, 44388, 44389, 44390, 44391, 44392, 44394, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408, 45379, 45382, 45386, 45389, 45390, 45391, 45393, 45398, 45399
• ICD10PCS: 0DTE0ZZ, 0DTE4ZZ, 0DTE7ZZ, 0DTE8ZZ

Routine Colonoscopy

• CPT: 45378, 45380, 45381, 45384, 45388
• HCPCS: G0105, G0121
• With Ambulatory Surgery POS:
  • 19- Off Campus-Outpatient Hospital
  • 22- On Campus-Outpatient Hospital
  • 24- Ambulatory Surgical Center

Irritable Bowel Diseases

• ICD-10-CM: K50.00, K50.011, K50.012, K50.013, K50.014, K50.018, K50.019, K50.10, K50.111, K50.112, K50.113, K50.114, K50.118, K50.119, K50.80, K50.811, K50.812, K50.813, K50.814, K50.818, K50.819, K50.90, K50.911, K50.912, K50.913, K50.914, K50.918, K50.919, K51.00, K51.011, K51.012, K51.013, K51.014, K51.018, K51.019, K51.20, K51.211, K51.212, K51.213, K51.214, K51.218, K51.219, K51.30, K51.311, K51.312, K51.313, K51.314, K51.318, K51.319, K51.40, K51.411, K51.412, K51.413, K51.414, K51.418, K51.419, K51.50, K51.511, K51.512, K51.513, K51.514, K51.518, K51.519, K51.80, K51.811, K51.812, K51.813, K51.814, K51.818, K51.819, K51.90, K51.911, K51.912, K51.913, K51.914, K51.918, K51.919, K57.20, K57.21, K57.32, K57.33, K57.40, K57.41, K57.52, K57.53, K57.80, K57.81, K57.92, K57.93

Malignant Neoplasms

• ICD-10-CM: C00.0- C96.Z*

Other Malignant Neoplasm of Skin

• ICD-10-CM: C44.00, C44.01, C44.02, C44.09, C44.101, C44.102, C44.1021, C44.1022, C44.109, C44.1091, C44.1092, C44.111, C44.112, C44.1121, C44.1122, C44.119, C44.1191, C44.1192, C44.121, C44.122, C44.1221, C44.1222, C44.129, C44.1291, C44.1292, C44.131, C44.1321, C44.1322, C44.1391, C44.1392, C44.191, C44.192, C44.1921, C44.1922, C44.199, C44.1991, C44.1992, C44.201, C44.202, C44.209, C44.211, C44.212, C44.219, C44.221, C44.222, C44.229, C44.291, C44.292, C44.299, C44.300, C44.301, C44.309, C44.310, C44.311, C44.319, C44.320, C44.321, C44.329, C44.390, C44.391, C44.399, C44.40, C44.41, C44.42, C44.49, C44.500, C44.501, C44.509, C44.510, C44.511, C44.519, C44.520, C44.521, C44.529, C44.590, C44.591, C44.599, C44.601, C44.602, C44.609, C44.611, C44.612, C44.619, C44.621, C44.622, C44.629, C44.691, C44.692, C44.699, C44.701, C44.702, C44.709, C44.711, C44.712, C44.719, C44.721, C44.722, C44.729, C44.791, C44.792, C44.799, C44.80, C44.81, C44.82, C44.89, C44.90, C44.91, C44.92, C44.99
  Chemotherapy Encounter ICD-10-CM: Z51.0, Z51.11, Z51.12

Rehabilitation

• ICD-10-CM: Z44.001, Z44.002, Z44.009, Z44.011, Z44.012, Z44.019, Z44.021, Z44.022, Z44.029, Z44.101, Z44.102, Z44.109, Z44.111, Z44.112, Z44.119, Z44.121, Z44.122, Z44.129, Z44.30, Z44.31, Z44.32, Z44.8, Z44.9, Z45.1, Z45.31, Z45.320, Z45.321, Z45.328, Z45.41, Z45.42, Z45.49, Z45.811, Z45.812, Z45.819, Z46.82, Z46.89, Z46.9

Kidney Transplant

• CPT: 50360, 50365, 50380
• HCPCS: S2065
• ICD-10-PCS: 0TY00Z0, 0TY00Z1, 0TY00Z2, 0TY10Z0, 0TY10Z1, 0TY10Z2

Bone Marrow Transplant

• ICD-10-PCS: 30230AZ, 30230C0, 30230G0, 30230G2, 30230G3, 30230G4, 30230U2, 30230U3, 30230U4, 30230X0, 30230X2, 30230X3, 30230X4, 30230Y0, 30230Y2, 30230Y3, 30230Y4, 30233AZ, 30233C0, 30233G0, 30233G2, 30233G3, 30233G4, 30233U2, 30233U3, 30233U4, 30233X0, 30233X2, 30233X3, 30233X4, 30233Y0, 30233Y2, 30233Y3, 30233Y4, 30240AZ, 30240C0, 30240G0, 30240G2, 30240G3, 30240G4, 30240U2, 30240U3, 30240U4, 30240X0, 30240X2, 30240X3, 30240X4, 30240Y0, 30240Y2, 30240Y3, 30240Y4, 30243AZ, 30243C0, 30243G0, 30243G2, 30243G3, 30243G4, 30243U2, 30243U3, 30243U4, 30243X0, 30243X2, 30243X3, 30243X4, 30243Y0, 30243Y2, 30243Y3, 30243Y4

Organ Transplant Other Than Kidney:

• CPT:32850, 32851, 32852, 32853, 32854, 32855, 32856, 33927, 33928, 33929, 33930, 33933, 33935, 33940, 33944, 33945, 44132, 44133, 44135, 44136, 44137, 44715, 44720, 44721, 47133, 47135, 47136, 47140, 47141, 47142, 47143, 47144, 47145, 47146, 47147, 48160, 48550, 48551, 48552, 48554, 48556
• HCPCS: S2053, S2054, S2055, S2060, S2061, S2152
• ICD-10-PCS: 02YA0Z0, 02YA0Z1, 02YA0Z2, 07YM0Z0, 07YM0Z1, 07YM0Z2, 07YP0Z0, 07YP0Z1, 07YP0Z2, 0BYC0Z0, 0BYC0Z1, 0BYC0Z2, 0BYD0Z0, 0BYD0Z1, 0BYD0Z2, 0BYF0Z0, 0BYF0Z1, 0BYF0Z2, 0BYG0Z0, 0BYG0Z1, 0BYG0Z2, 0BYH0Z0, 0BYH0Z1, 0BYH0Z2, 0BYJ0Z0, 0BYJ0Z1, 0BYJ0Z2, 0BYK0Z0, 0BYK0Z1, 0BYK0Z2, 0BYL0Z0, 0BYL0Z1, 0BYL0Z2, 0BYM0Z0, 0BYM0Z1, 0BYM0Z2, 0DY50Z0, 0DY50Z1, 0DY50Z2, 0DY60Z0, 0DY60Z1, 0DY60Z2, 0DY80Z0, 0DY80Z1, 0DY80Z2, 0DYE0Z0, 0DYE0Z1, 0DYE0Z2, 0FY00Z0, 0FY00Z1, 0FY00Z2, 0FYG0Z0, 0FYG0Z1, 0FYG0Z2, 0UY00Z0, 0UY00Z1, 0UY00Z2, 0UY10Z0, 0UY10Z1, 0UY10Z2, 0UY90Z0, 0UY90Z1, 0UY90Z2, 0WY20Z0, 0WY20Z1, 0XYJ0Z0, 0XYJ0Z1, 0XYK0Z0, 0XYK0Z1, 3E030U0, 3E030U1, 3E033U0, 3E033U1, 3E0J3U0, 3E0J3U1, 3E0J7U0, 3E0J7U1, 3E0J8U0, 3E0J8U1

Introduction of Autologous Pancreatic Cells

• ICD-10-PCS: 3E030U0, 3E030U1, 3E033U0, 3E033U1, 3E0J3U0, 3E0J3U1, 3E0J7U0, 3E0J7U1, 3E0J8U0, 3E0J8U1

Potentially Planned Procedures

• ICD-10-PCS: 0210083- XRGD092*
• With Acute Condition ICD-10-CM: A00.0-Z99.89*

* To obtain the full Acute Hospitalization Following Outpatient Colonoscopy Value Set, please reach out to your Provider Engagement Liaison or email [email protected].

Measure Codes

Inpatient Stay

• UBREV: 0100, 0101, 0110, 0111, 0112, 0113, 0114, 0116, 0117, 0118, 0119, 0120, 0121, 0122, 0123, 0124, 0126, 0127, 0128, 0129, 0130, 0131, 0132, 0133, 0134, 0136, 0137, 0138, 0139, 0140, 0141, 0142, 0143, 0144, 0146, 0147, 0148, 0149, 0150, 0151, 0152, 0153, 0154, 0156, 0157, 0158, 0159, 0160, 0164, 0167, 0169, 0170, 0171, 0172, 0173, 0174, 0179, 0190, 0191, 0192, 0193, 0194, 0199, 0200, 0201, 0202, 0203, 0204, 0206, 0207, 0208, 0209, 0210, 0211, 0212, 0213, 0214, 0219, 1000, 1001, 1002

Observation Stay

• UBREV: 0760, 0762, 0769