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Johns Hopkins Health Plans

COL-E - Colorectal Cancer Screening

Product Lines:
Advantage MD, Dual Eligible Special Needs Plans (D-SNP), EHP, Priority Partners and USFHP.

Measurement Period: January 1 - December 31

Description: The percentage of persons 45-75 years of age who had appropriate screening for colorectal cancer.

Stratifications: 
Age as of the last day of the measurement period.

  • 46–50 years.
  • 51–75 years.

Report stratification by race and ethnicity.
Report Stratification by SES only for Advantage MD (Medicare product line). 

Measure Reporting:
CMS Start Rating Measure.  

Improvement Notation:
Increased score indicates improvement. 

Data Collection:

  • ECDS.  

Initial Population:

  • Measure Item Count: Person.
  • Age: 46–75 years of age as of the last day of the measurement period.
  • Benefits: Medical.
  • Continuous Enrollment: The measurement period and the year prior to the measurement period.
  • Allowable Gap: No more than one gap of ≤45 days during each year of the continuous enrollment period. No gaps on the last day of the measurement period.

Denominator:
The initial population minus denominator exclusions.

Numerator:
Persons with one or more screenings for colorectal cancer.
Any of the following meet criteria:

  • Fecal occult blood test during the measurement period. 
  • Stool DNA (sDNA) with FIT test during the measurement period or the 2 years prior to the measurement period.
  • Flexible sigmoidoscopy during the measurement period or the 4 years prior to the measurement period. 
  • CT colonography during the measurement period or the 4 years prior to the measurement period.
  • Colonoscopy during the measurement period or the 9 years prior to the measurement period.

Best Practice and Measure Tips

  • Best practice to have the actual screening test and result. However, result is not required as long as documentation is part of the medical record and clearly indicates screening was completed and not merely ordered. If this is not clear, the result or finding must also be present.
    • The person's "medical history" can be located within any section of the person's medical record in order to count, including the treatment/plan, problem list, progress note, health maintenance summary, HPI etc.
    • If the colonoscopy is documented in the "medical history" section of the medical record, then a result/finding is not required regardless of the setting (i.e., inpatient, outpatient or member reported).
      • Examples of notation in person's medical history:
        • “Colonoscopy 6/2021”
        • “Last colonoscopy 2021”
        • “H/O colonoscopy 2021”
        • “Had last colonoscopy in 2021 per pt.”
        • Provider documentation states “colonoscopy done earlier this year”
  • Always include a date of service and place of service if known.    
  • Member refusal will not make them ineligible for this measure.
  • Educate member about the importance of early detection and recommend a different screening if a person refuses or can’t tolerate a colonoscopy.**
  • Have FIT kits available to give members during the visit with instructions to return them to the office or mail to the lab.**
  • Update and document the person's history annually including type and date of colon cancer screening tests, history of total colectomy, or history of colon cancer.

**Note: A stool DNA (sDNA) with FIT test is Cologuard. A FIT test is the FOBT immunochemical test. They are not the same.

Acceptable:

FOBT

  • Two types of FOBT tests: guaiac (gFOBT) CPT 82270 and immunochemical (iFOBT/FIT) CPT 82274. Depending on the type of FOBT test, a certain number of samples are required for numerator compliance. 
  • The fecal immunochemical test (FIT) (iFOBT) uses antibodies to detect blood in the stool. Foods do not alter test results.
    • Regardless of how many samples were returned and as long as the medical record indicates that a FIT was done, the patient meets criteria.
  • The guaiac-based fecal occult blood test (gFOBT) uses the chemical guaiac to detect blood in the stool. Three consecutive stool specimens are required to be collected by the patient for a single determination for colorectal neoplasm screening. Certain foods can alter test results.
    • For gFOBT and unspecified type of test:
      • If the medical record does not indicate the number of samples (assume correct number returned) OR indicates three or more samples were returned, the patient meets criteria.
      • If the medical record indicates one or two samples were returned, the patient DOES NOT meet criteria.
  • The FOBT test must be processed and results reported by a lab.
  • Documentation in the medical record of “Colon Cancer Screening Done in 2026” without notation of type of screening can only be used as evidence of FOBT.

Procedures

  • Inpatient or outpatient procedures.
  • Member reported services recorded, dated and maintained in the patient's legal health record.
  • A result is not required if documentation includes:
    • Type of screening (colonoscopy, flexible sigmoidoscopy, etc.)
    • Date the test was performed, this is considered part of the patient's medical history and a result is not required.
  • Procedures documented during the patient’s history by a primary care practitioner—or by a specialist functioning in a primary care capacity for the condition being assessed—are counted toward the measure. 
  • Colonoscopy or Flexible sigmoidoscopy procedure reports with documentation that indicates a complete exam.
  • Documentation Requirements: If the pathology report does not indicate the screening type, or if the procedure report notes an incomplete exam or inadequate bowel prep, please ensure the documentation shows how far the scope advanced. 
    • To the Cecum = colonoscopy.
    • To the sigmoid colon = flexible sigmoidoscopy.
    • Procedure Reports: Documentation within the procedure report is used to validate the clinical evidence required for measure compliance.
    • Pathology Reports: The documented anatomical location of each specimen is used to determine the extent of colonic advancement during the procedure. 
    • Determining the Procedure Date from a Pathology Report  
      • When the pathology report lists the screening type, the collection date, and the result date, the collection date is used, as this reflects the actual procedure date.
      • If a collection date is not documented, the result date may be used as the procedure date. 

Not Acceptable:

  • Tests performed in an office setting or from any specimen collected during a digital rectal exam (DRE).
  • The guaiac-based FOBT (gFOBT), CPT code 82270, is designated specifically for colorectal neoplasm screening and is not intended for diagnostic use in any clinical setting.     
  • CT scan of the abdomen and pelvis. (It is not the same as a CT Colonography and is not acceptable.)
  • Unclear documentation in medical record as “COL” or “COLON 20XX” by provider without mention of the actual screening test completed.
  • Colonoscopy indicating “poor bowel prep” or “incomplete exam” without documentation scope advanced to cecum for a colonoscopy or into the sigmoid colon for flexible sigmoidoscopy.

Measure Exclusions

Denominator Exclusions:

  • Persons receiving palliative care or who had an encounter for palliative care any time during the measurement period. 
  • Persons in hospice or using hospice services any time during the measurement period.
  • Persons 66 years of age or older by the last day of the measurement period, with both frailty and advanced illness.
  • Colorectal cancer or a total colectomy any time during the person's history through the last day of the measurement period.
  • Persons who died any time during the measurement period.
  • Medicare enrollees, 66 years of age and older by the last day of the measurement period, in an institutional SNP (I-SNP) or living long-term in an institution (LTI). 

Exclusion Codes

Colorectal Cancer 

  • ICD-10-CM: C18.0, C18.1, C18.2, C18.3, C18.4, C18.5, C18.6, C18.7, C18.8, C18.9,  C19, C20, C21.2, C21.8, C78.5, Z85.038, Z85.048
  • SNOMED CT US Edition: 93683002, 93761005, 93771007, 93826009, 93980002, 93984006, 94006002, 94072004, 94105000, 94179005, 94260004, 94271003, 94328005, 94509004, 94513006, 94538001, 94604000, 94643001, 109838007, 109839004, 109840002, 187757001, 187758006, 187760008, 254582000, 254586002, 269533000, 269544008, 276822007, 285312008, 285611007, 285612000, 301756000, 312111009, 312112002, 312113007, 312114001, 312115000, 314965007, 314966008, 315058005, 363351006, 363406005, 363407001, 363408006, 363409003, 363410008, 363412000, 363413005, 363414004, 363491008, 363510005, 369448007, 369449004, 369450004, 369451000, 369452007, 369453002, 369454008, 369455009, 369456005, 369457001, 369458006, 369459003, 369460008, 369461007, 395705003, 422375001, 422581008, 422985007, 425178004, 425213009, 429084005, 429699009, 443488001, 447886005, 448994001, 449218003, 713573006, 721695008, 721696009, 721697000, 721698005, 721699002, 721700001, 721701002, 726654006, 737058005, 766979005, 766981007, 1156783003, 1156788007, 1156795003, 1156797006, 1162856006, 1163568002, 1186811008, 1197354001, 1197355000, 1197359006, 1204448006, 1237454003, 1237455002, 1237456001, 1237458000, 1237460003, 1237480002, 1237484006, 1237485007, 1259403004, 1259404005, 1259405006, 1259406007, 1259407003, 1259432001, 1259436003, 1259437007, 1268633007, 1268635000, 1269123008, 1287662001, 1287666003, 1288026004, 1288027008, 1288028003, 1288029006, 1288033004, 1290068000, 1290085003, 1290086002, 1290087006, 1290274008, 1701000119104, 96281000119107, 96981000119102, 123691000119104, 123701000119104, 123721000119108, 130381000119103, 133751000119102, 184881000119106, 286771000119106, 286791000119107, 681601000119101, 681651000119102, 801171000124106, 801181000124109, 10987871000119109, 16636051000119105, 16636101000119105 

Total Colectomy 

  • CPT: 44150, 44151, 44152, 44153, 44155, 44156, 44157, 44158, 44210, 44211, 44212
  • ICD-10-PCS: 
    • [0DTE0ZZ] Resection of Large Intestine, Open Approach
    • [0DTE4ZZ] Resection of Large Intestine, Percutaneous Endoscopic Approach
    • [0DTE7ZZ] Resection of Large Intestine, Via Natural or Artificial Opening
    • [0DTE8ZZ] Resection of Large Intestine, Via Natural or Artificial Opening Endoscopic
  • SNOMED CT code: 119771000119101, 456004, 26390003, 31130001, 36192008, 44751009, 80294005, 303401008, 307666008, 307667004, 307669001, 713165008, 787108001, 787109009, 787874000, 787875004, 787876003, 858579005 

Measure Codes

  • Colonoscopy 
    • CPT: 44388, 44389, 44390, 44391, 44392, 44394, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45388, 45389, 45390, 45391, 45392, 45393, 45398
    • HCPCS: G0105, G0121
    • SNOMED CT: 851000119109, 8180007, 12350003, 25732003, 73761001, 174158000, 174171002, 174173004, 174179000, 174185007, 235150006, 302052009, 311774002, 367535003, 426699005, 443998000, 444783004, 446521004, 446745002, 447021001, 609197007, 709421007, 710293001, 711307001, 771568007, 773128008, 773129000, 789778002, 1209098000, 1217313001, 1304042004, 1304043009, 1304044003, 1304045002, 1304049008, 1304050008, 1351202006, 10371000132109, 48021000087103, 48031000087101 
  • Flexible Sigmoidoscopy 
    • CPT: 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45340, 45341, 45342, 45346, 4 5347, 45349, 45350
    • HCPCS: G0104
    • SNOMED CT: 841000119107, 44441009, 396226005, 425634007
  • FOBT Lab Test 
    • Guaiac Test (gFOBT):  CPT: 82270
    • FIT Test Immunochemical (iFOBT/FIT):
      • CPT: 82274
      • HCPCS: G0328
    • LOINC: 104738-0, 107189-3, 107190-1, 107191-9, 12503-9, 12504-7, 14563-1, 14564-9, 14565-6, 2335-8, 27396-1, 27401-9, 27925-7, 27926-5, 29771-3, 56490-6, 56491-4, 57905-2, 58453-2, 80372-6
    • FOBT Test Result or Finding SNOMED CT: 59614000, 167667006, 389076003, 71711000112103
  • Computed Tomography (CT) Colonography 
    • CPT: 74261, 74262, 74263 
    • LOINC: 60515-4, 72531-7, 79069-1, 79071-7, 79101-2, 82688-3
    Stool DNA (sDNA) with FIT Test 
    • CPT 81528 This code is specific to the Cologuard® sDNA with FIT test.
    • CPT Code: 0464U- Oncology (colorectal) screening, quantitative real-time target and signal amplification, methylated DNA markers, including LASS4, LRRC4 and PPP2R5C, a reference marker ZDHHC1, and a protein marker (fecal hemoglobin), utilizing stool, algorithm reported as a positive or negative result
      •  CPT code 0464U is used when a clinician orders the Cologuard Plus™ test for colorectal cancer screening.
    • LOINC: 77353-1, 77354-9
    • SNOMED CT: 708699002