Colorectal Cancer Screening (COL) is retired, only COL-E measure will be reported.

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

Eligible Population:
Members age 45-75 years as of December 31 of the measurement year.

Definition:
Members age 45-75 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 or flexible sigmoidoscopy every 10 years, with FIT every year.
• CT Colonography (Virtual colonoscopy) during the MY or the four (4) years prior.
• Stool DNA (sDNA) with FIT test (Cologuard) during the MY or two (2) years prior.
• Fecal occult blood test (FOBT) during the MY. gFOBT (guaiac), FIT/iFOBT (immunochemical).

Members 46–75 years as of December 31 of the measurement year. Report two age stratifications and a total rate:

• 46–49 years.
• 50–75 years.
• Total. *** The total is the sum of the age stratifications.

Report Stratification by race and ethnicity.

*Note: Only the administrative data collection method may be used when reporting this measure for Priority Partners (Medicaid product line). There will be no medical records review. 

Continuous Enrollment:

• The measurement period and the year 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 member's "medical history" can be located within any section of the member'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 member’s medical history:
      • “Colonoscopy 6/2021”
      • “Last colonoscopy 2015”
      • “H/O colonoscopy 2021”
      • “Had last colonoscopy in 2016 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 member 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.
• Updated and document the member’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: 

• 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. 
  • 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 member meets criteria.
  • The guaiac-based fecal occult blood test (gFOBT) uses the chemical guaiac to detect blood in the stool. 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 member meets criteria.
• The FOBT test must be processed and results reported by a lab.
• Documentation in the medical record of “Colon Cancer Screening Done in 2022” without notation of type of screening can only be used as evidence of FOBT.
• Inpatient or outpatient procedures.
• Member reported services recorded, dated and maintained in the member'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 member's medical history and a result is not required.
  • Collected while taking a patient’s history by a primary care practitioner or a specialist who is providing a primary care service related to the condition being assessed.
• Colonoscopy or Flexible sigmoidoscopy procedure reports with documentation that indicates a complete exam.
• Documentation Requirements: Using Pathology Reports, Incomplete or Poor Prep Exams.
  • If a pathology report does not indicate the type of screening, or if the procedure report indicates an incomplete exam or poor prep, Look for evidence of where scope advanced to:
    • To the Cecum = colonoscopy.
    • To the sigmoid colon = flexible sigmoidoscopy.
      • From a procedure report: refer to the report documentation for evidence.
      • From a pathology report: Look for location in colon where specimen(s) was removed from to identify how far the scope advanced.
        • Example: “Polyp removed from ascending colon.” This member would be compliant for flexible sigmoidoscopy only. Attempt to locate procedure report to verify if member had a colonoscopy.
  • To determine date of procedure from a Pathology Report:
    • If report indicates the type of screening, the date the screening was performed (collected date) and resulted date, use collected date since this is the procedure date.
    • If collected date is not available, the resulted date can be used.

Not Acceptable:

• Tests performed in an office setting or from any specimen collected during a digital rectal exam (DRE).
• 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

Required Exclusions:

• Palliative Care
• Members in hospice or using hospice services anytime during the measurement year.
• Frailty and Advanced Illness
• Living in Long Term Care.
• Members who had colorectal cancer or a total colectomy any time during the member’s history through December 31 of the measurement year.
• Members who died any time during the measurement year.

Exclusion Codes:

• Colorectal Cancer 
  • ICD-10-CM: 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
  • 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
  • SNOMED CT code: 119771000119101

Measure Codes

• Colonoscopy 
  • CPT: 44388, 44389, 44390, 44391, 44392, 44394, 44401-44408, 45378,45379, 45380, 45381, 45382, 45384, 45385, 45386, 45388, 45389, 45390, 45391, 45392, 45393, 45398
  • HCPCS: G0105, G0121
  • SNOMED CT: 851000119109, 8180007, 12350003, 25732003, 34264006, 73761001, 174158000, 174185007, 235150006, 235151005, 275251008, 302052009, 367535003, 443998000, 444783004, 446521004, 446745002, 447021001, 709421007, 710293001, 711307001, 789778002, 1209098000
• Flexible Sigmoidoscopy 
  • CPT: 45330-45335, 45337, 45338, 45340-45342, 45346,45347, 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: 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
  • SNOMED CT: 104435004, 441579003, 442067009, 442516004, 442554004, 442563002
  • FOBT Test Result or Finding SNOMED CT: 59614000, 167667006, 389076003
• Computed Tomography (CT) Colonography 
  • CPT:74261-74263
  • LOINC: 60515-4, 72531-7, 79069-1, 79071-7, 79101-2, 82688-3
  • SNOMED CT: 418714002
• Stool DNA (sDNA) with FIT Test 
  • CPT 81528 This code is specific to the Cologuard® sDNA with FIT test.
  • LOINC: 77353-1, 77354-9
  • SNOMED CT: 708699002