In This Section      

Colorectal Cancer Screening

Advantage MD, EHP, and USFHP. Members 50-75 years of age.

Members age 50-75 who received one or more of the following screenings for colorectal cancer:

  • Colonoscopy (also known as lower endoscopy) during the MY or the (9) years prior.
  • Flexible sigmoidoscopy during the MY or the four (4) years prior.
  • CT Colonography (Virtual colonoscopy) during the MY or the four (4) years prior.
  • FIT DNA test (Cologuard) during the MY or two (2) years prior.
  • Fecal occult blood test (FOBT) during the MY. gFOBT (guaiac), FIT/iFOBT (immunochemical).

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.
  • Always include a date of service – year only is acceptable – when documenting screening reported by the member.
  • Member refusal will not make them ineligible for this measure – recommend other screeningif a member refuses or can’t tolerate a colonoscopy.

Acceptable: Colonoscopy indicating "poor bowel prep" or "incomplete exam" with documentation of scope advancing past splenic flexure for a colonoscopy or advancing into sigmoid colon for flexible sigmoidoscopy.

  • Two types of FOBT tests: guaiac (gFOBT) and immunochemical (iFOBT/FIT). Depending on the type of FOBT test, a certain number of samples are required for numerator compliance.
    • For FIT test: as long as the medical record indicates that a FIT was done, the member meets criteria regardless of how many samples were returned.
    • 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 member meets criteria.
  • The FOBT test must be processed and results reported by a lab.
  • The advanced illness exclusion can be identified from a telephone visit, e-visit or virtual check-in.

Not Acceptable: Tests performed in an office setting or from any specimen collected during a digital rectal exam (DRE).

Measure Exclusions

Required Exclusions:

  • Palliative Care
  • Hospice
  • Fraility
  • Fraility and Advanced Illness
  • Living in Long Term Care.

Optional Exclusions (Any time in a member’s history through Dec. 31 of the measurement year, submit ICD-10 diagnosis code on any visit claim):

  • Total colectomy
  • Colorectal cancer

Measure Codes

  • Colonoscopy
    • CPT: 44388-44394, 44397, 44401-44408, 45355, 45378-45393, 45398
    • HCPCS: G0105, G0121
  • Flexible Sigmoidoscopy
    • CPT: 45330-45335, 45337-45342, 45345-45347, 45349 – 45350
    • HCPCS: 60104
  • FOBT Lab Test
    • CPT: 82270
    • HCPCS: G0328
  • Computed Tomography (CT) Colonography
    • CPT/CPT II 74261-63
  • FIT-DNA Test
    • CPT/CPT II: 81528 This code is specific to the Cologuard® FIT-DNA test.
    • HCPCS: G0464 This code was retired and replaced with CPT code 81528
  • FIT
    • CPT/CPT II: 82274

Exclusion Codes:

  • Colorectal Cancer
    • HCPCS: G0213, G0214, G0215, G0231
    • ICD-10: C18.0-C18.9, C19, C20, C21.2, C21.8, C78.5, Z85.038, Z85.048
  • Total Colectomy
    • CPT: 44150-44153, 44155-44158, 44210-44212