(MIPS) includes 5 endoscopy / colorectal cancer (CRC) …endoscopy... · (ACG), the American...

The 2017 CMS Merit-based Incentive Payment System (MIPS) includes 5 endoscopy / colorectal cancer

(CRC) screening and surveillance measures co-owned by the American College of Gastroenterology

(ACG), the American Gastroenterological Association (AGA, and the American Society of Gastrointestinal

Endoscopy (ASGE).

Measure Specifications for Claims Reporting

MIPS #185: Colonoscopy Interval for Patients with a History of Adenomatous Polyps –Avoidance

of Inappropriate Use *

MIPS #320: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients *

MIPS #425: Photodocumentation of Cecal Intubation **

Measure Specifications for Registry Reporting

MIPS #185: Colonoscopy Interval for Patients with a History of Adenomatous Polyps –Avoidance

of Inappropriate Use *

MIPS #320: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients *

MIPS #343: Screening Colonoscopy Adenoma Detection Rate **

MIPS #425: Photodocumentation of Cecal Intubation **

MIPS #439: Age Appropriate Screening Colonoscopy *

The 2017 CMS Ambulatory Surgical Center Quality Reporting program includes two endoscopy /

colorectal cancer (CRC) screening and surveillance measures.

Measure Specifications for Ambulatory Surgical Center Quality Reporting

ASC-9: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients *

ASC-10: Colonoscopy Interval for Patients with a History of Adenomatous Polyps –Avoidance of

Inappropriate Use *

* AGA-stewarded measure

** ASGE-stewarded measure

Measure. #185 (NQF 0659): Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use – National Quality Strategy Domain: Communication and CareCoordination

2017 OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS ONLY

MEASURE TYPE: Process

DESCRIPTION: Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a 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 reported each time a surveillance colonoscopy is performed during the performance period. It is anticipated the eligible clinician who performs the listed procedures, as specified in the denominator coding, will report 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 Reporting: The listed denominator criteria is used to identify the intended patient population. The numerator quality-data codes included in this specification are used to submit the quality actions allowed by the measure. All measure-specific coding should be reported on the claim(s) representing the eligible encounter.

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: 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

NUMERATOR: Patients who had an interval of 3 or more years since their last colonoscopy

Numerator Quality-Data Coding Options: Interval of Three or More Years Since Patient’s Last Colonoscopy Performance Met: CPT II 0529F: Interval of 3 or more years since patient’s last

colonoscopy, documented

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CPT only copyright 2016 American Medical Association. All rights reserved. 1 of 6

OR Interval of Less Than Three Years Since Patient’s Last Colonoscopy for Medical or System Reasons Append a modifier (1P or 3P) to CPT Category II code 0529F to report documented circumstances that appropriately exclude patients from the denominator. Denominator Exception: 0529F with 1P: Documentation of medical reason(s) for an interval of

less than 3 years since the last colonoscopy (eg, 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])

OR Denominator Exception: 0529F with 3P: Documentation of system reason(s) for an interval

of less than 3 years since the last colonoscopy (eg, unable to locate previous colonoscopy report, previous colonoscopy report was incomplete)

OR Interval of Less Than Three Years Since Patient’s Last Colonoscopy, Reason not Otherwise Specified Append a reporting modifier (8P) to CPT Category II code 0529F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified. Performance Not Met: 0529F with 8P: Interval of less than 3 years since patient’s last

colonoscopy, reason not otherwise specified

RATIONALE: Colorectal cancer is the 2nd leading cause of cancer 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 5–10 years; 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). Patients with 3 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 providing that piecemeal removal has not been performed and the adenoma(s) are removed completely; if the follow-up colonoscopy is normal or shows only 1 or 2 small tubular adenomas with low-grade dysplasia, then the interval for the subsequent examination should be 5 years. (Winawer, et al, 2006)

Patients with > 10 adenomas are thought to be at particularly high risk, and current multi-society guidelines therefore recommend early surveillance colonoscopy in these individuals (< 3 years). (Lieberman, et al, 2012) 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

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adenoma). A lower threshold is likely to result in higher colonoscopy utilization, but it may also provide greater clinical benefit. (Martinez, et al, 2012)

COPYRIGHT The Measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications.

The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, eg, use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain.

Commercial uses of the Measures require a license agreement between the user and the American Medical Association (AMA), [on behalf of the Physician Consortium for Performance Improvement® (PCPI®)] or the American Gastroenterological Association (AGA), or American Society for Gastrointestinal Endoscopy (ASGE) or the American College of Gastroenterology (ACG). Neither the AMA, AGA, ASGE, ACG, PCPI, nor its members shall be responsible for any use of the Measures.

The AMA’s, PCPI’s and National Committee for Quality Assurance’s significant past efforts and contributions to the development and updating of the Measures is acknowledged. AGA, ASGE and ACG are solely responsible for the review and enhancement (“Maintenance”) of the Measures as of August 14, 2014.

AGA, ASGE and ACG encourage use of the Measures by other health care professionals, where appropriate.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.

© 2015 American Medical Association, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy and American College of Gastroenterology. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, AGA, ASGE, ACG, the PCPI and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specifications.

CPT® contained in the Measures specifications is copyright 2004-2016 American Medical Association. LOINC®

copyright 2004-2016 Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT®) copyright 2004-2016 College of American Pathologists. All Rights Reserved.

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2017 Claims Individual Measure Flow #185 NQF #0659: Colonoscopy Interval for Patients with a History of Adenomatous Polyps –

Avoidance of Inappropriate Use Please refer to the specific section of the Measure Specification to identify the denominator and numerator information for use in reporting this Individual Measure.

1. Start with Denominator

2. Check Patient Age:

a. If the Age is greater than or equal to 18 years of age at Date of Service and equals No during the measurement period, do not include in Eligible Patient Population. Stop Processing.

b. If the Age is greater than or equal to 18 years of age at Date of Service and equals Yes during the measurement period, proceed to check Encounter Performed.

3. Check Patient Diagnosis:

a. If Diagnosis for History of Colonic Polyp (s) as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing.

b. If Diagnosis for History of Colonic Polyp (s) as Listed in the Denominator equals Yes, proceed to check Procedure Performed.

4. Check Procedure Performed:

a. If Procedure as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing.

b. If Procedure as Listed in the Denominator equals Yes, proceed to check Modifiers: 52, 53, 73, or 74.

5. Check Modifiers: 52, 53, 73, or 74:

a. If Modifiers: 52, 53, 73, or 74 equals No, include in the Eligible Population.

b. If Modifiers: 52, 53, 73, or 74 equals Yes, do not include in Eligible Patient Population. Stop Processing.

6. Denominator Population:

a. Denominator population is all Eligible Patients in the denominator. Denominator is represented as Denominator in the Sample Calculation listed at the end of this document. Letter d equals 8 procedures in the sample calculation.

7. Start Numerator

8. Check Interval of Three or More Years Since Patient’s Last Colonoscopy:

a. If Interval of Three or More years Since Patient’s Last Colonoscopy equals Yes, include in Data Completeness Met and Performance Met.

b. Data Completeness Met and Performance Met letter is represented in the Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter a equals 3 procedures in Sample Calculation.

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c. If Interval of Three or More Years Since Patient’s Last Colonoscopy equals No, proceed to Interval ofLess Than Three Years Since Patient’s Last Colonoscopy for Medical Reasons.

9. Check Interval of Less Than Three Years Since Patient’s Last Colonoscopy for Medical Reasons:

a. If Interval of Less Than Three Years Since Patient’s Last Colonoscopy for Medical Reasons equals Yes,include in Data Completeness Met and Denominator Exception.

b. Data Completeness Met and Denominator Exception letter is represented in the Data Completenessand Performance Rate in the Sample Calculation listed at the end of this document. Letter b1 equals 1procedure in the Sample Calculation.

c. If Interval of Less Than Three Years Since Patient’s Last Colonoscopy for Medical Reasons equals No,proceed to Interval of Less Than Three Years Since Patient’s Last Colonoscopy for System Reasons.

10. Check Interval of Less Than Three Years Since Patient’s Last Colonoscopy for System Reasons:

a. If Interval of Less Than Three Years Since Patient’s Last Colonoscopy for System Reasons equals Yes,include in the Data Completeness Met and Denominator Exception.


c. If Interval of Less Than Three Years Since Patient’s Last Colonoscopy for System Reasons equals No,proceed to Interval of Less Than Three Years Since Patient’s Last Colonoscopy, Reason Not Specified.

11. Check Interval of Less Than Three Years Since Patient’s Last Colonoscopy, Reason Not Specified:

a. If Interval of Less Than Three Years Since Patient’s Last Colonoscopy, Reason Not Specified equalsYes, include in Data Completeness Met and Performance Not Met.

b. Data Completeness Met and Performance Not Met letter is represented in the Data Completeness in theSample Calculation listed at the end of this document. Letter c equals 2 procedures in the SampleCalculation.

c. If Interval of Less Than Three Years Since Patient’s Last Colonoscopy, Reason Not Specified equalsNo, proceed to Data Completeness Not Met.

12. Check Data Completeness Not Met:

a. If Data Completeness Not Met equals No, Quality Data Code not reported. 1 procedure has beensubtracted from the data completeness numerator in the sample calculation.

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Measure #320 (NQF 0658): Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients – National Quality Strategy Domain: Communication and Care Coordination



DESCRIPTION: Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report

INSTRUCTIONS: This measure is to be reported a minimum of once per performance period for patients seen during the performance period. Performance for this measure is not limited to the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on services provided and the measure- specific denominator coding. Patients who have a coded colonoscopy procedure that has a modifier 52, 53, 73, or 74 will not qualify for inclusion into the measure.


DENOMINATOR: All patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy

Denominator Instructions: 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 50 to 75 on date of encounter AND Patient undergoing screening for malignant neoplasm of colon (ICD-10-CM): Z12.11 AND Patient procedure during the performance period (CPT or HCPCS): 44388, 45378, G0121 WITHOUT Modifiers: 52, 53, 73, or 74

NUMERATOR: Patients who had recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report

Numerator Quality-Data Coding Options: At Least 10 Year Follow-Up Interval for Colonoscopy Recommended Performance Met: CPT II 0528F: Recommended follow-up interval for repeat

colonoscopy of at least 10 years documented in colonoscopy report

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OR At Least 10 Year Follow-Up Interval for Colonoscopy not Recommended for Medical Reasons Append a modifier (1P) to CPT Category II code 0528F to report documented circumstances that appropriately exclude patients from the denominator. Denominator Exception: 0528F with 1P: Documentation of medical reason(s) for not

recommending at least a 10 year follow-up interval (e.g., inadequate prep, familial or personal history of colonic polyps, patient had no adenoma and age is ≥ 66 years old, or life expectancy < 10 years old, other medical reasons)

OR At Least 10 Year Follow-Up Interval for Colonoscopy not Recommended, Reason not Otherwise Specified Append a reporting modifier (8P) to CPT Category II code 0528F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified. Performance Not Met: 0528F with 8P: At least 10 year follow-up interval for colonoscopy

not recommended, reason not otherwise specified

RATIONALE: In the average-risk population, colonoscopy screening is recommended in all current guidelines at 10-year intervals. 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, 2008). The most common serious complication of colonoscopy is post-polypectomy bleeding (Levin et al, 2008).

Variations in the recommended time interval between colonoscopies exist for patients with normal colonoscopy findings. In a 2006 study of 1282 colonoscopy reports, recommendations were consistent with contemporaneous guidelines in only 39.2% of cases and with current guidelines in 36.7% of cases. Further, the adjusted mean number of years in which repeat colonoscopy was recommended was 7.8 years following normal colonoscopy (Krist et al, 2007)

CLINICAL RECOMMENDATION STATEMENTS: At present, CSPY (colonoscopy) every 10 years is an acceptable option for CRC screening in average-risk adults beginning at age 50 years. (ACS/USMSTF/ACR, 2008). The USPSTF recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until the age of 75 years. The risks and benefits of these screening methods vary (Grade A Recommendation) (USPTF, 2008).

The USPSTF recommends against “routine” screening for colorectal cancer in adults 76 to 85 years of age who have been adequately screened. There may be considerations that support colorectal cancer screening in an individual patient (Grade C Recommendation) (USPSTF, 2008).The preferred CRC prevention test is colonoscopy every 10 years, beginning at age 50. (Grade 1B) (Rex, et al, 2009)

COPYRIGHT: The Measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications.

The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain.

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2017 Claims Individual Measure Flow #320 NQF #0658: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients

Please refer to the specific section of the Measure Specification to identify the denominator and numerator information for use in reporting this Individual Measure.



a. If the Age is 50 to 75 years of age at Date of Service and equals No during the measurement period, do not include in Eligible Patient Population. Stop Processing.

b. If the Age is 50 to 75 years of age at Date of Service and equals Yes during the measurement period, proceed to check Patient Undergoing Screening for Malignant Neoplasm of Colon.

3. Check Patient Undergoing Screening for Malignant Neoplasm of Colon:

a. If Patient Understanding Screening for Malignant Neoplasm of Colon equals No, do not include in Eligible Patient Population. Stop Processing.

b. If Patient Understanding Screening for Malignant Neoplasm of Colon equals Yes, proceed to check Procedure Performed.






b. If Modifiers: 52, 53, 73, or 74 Codes equals Yes, do not include in Eligible Patient Population. Stop Processing.


a. Denominator population is all Eligible Patients in the denominator. Denominator is represented as Denominator in the Sample Calculation listed at the end of this document. Letter d equals 8 patients in the sample calculation.

7. Start Numerator

8. Check Recommended Follow-Up Interval for Repeat Colonoscopy of at Least 10 Years and Documented in Colonoscopy Report:

a. If Recommended Follow-Up Interval for Repeat Colonoscopy of at Least 10 Years and Documented in Colonoscopy Report equals Yes, include in Data Completeness Met and Performance Met.

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b. Data Completeness Met and Performance Met letter is represented in the Data Completeness andPerformance Rate in the Sample Calculation listed at the end of this document. Letter a equals 4patients in the Sample Calculation.

c. If Recommended Follow-Up Interval for Repeat Colonoscopy of at Least 10 Years and Documented inColonoscopy Report equals No, proceed to Documentation of Medical Reason(s) for notRecommending at Least a 10 Year Follow-up Interval.

9. Check Documentation of Medical Reason(s) for not Recommending at Least a 10 Year Follow-up Interval:

a. If Documentation of Medical Reason(s) for not Recommending at Least a 10 Year Follow-up Intervalequals Yes, include in Data Completeness Met and Denominator Exception.

b. Data Completeness Met and Denominator Exception is represented in the Data Completeness andPerformance Rate in the Sample Calculation listed at the end of this document. Letter b equals 1 patientin the Sample Calculation.

c. If Documentation of Medical Reason(s) for not Recommending at Least a 10 Year Follow-up Intervalequals No, proceed to At Least 10 Year Follow-Up Interval for Colonoscopy Not Recommended,Reason not Specified.

10. Check At Least 10 Year Follow-Up Interval for Colonoscopy Not Recommended, Reason Not Specified:

a. If At Least 10 Year Follow-Up Interval for Colonoscopy Not Recommended, Reason Not Specifiedequals Yes, include in Data Completeness Met and Performance Not Met.

b. Data Completeness Met and Performance Not Met is represented in the Data Completenes in theSample Calculation listed at the end of this document. Letter c equals 2 patients in the SampleCalculation.

c. If At Least 10 Year Follow-Up Interval for Colonoscopy Not Recommended, Reason Not Specifiedequals No, proceed to Data Completeness Not Met.


a. If Data Completeness Not Met equals No, Quality Data Code not reported. 1 patient has beensubtracted from the Data Completeness numerator in the same calculation.

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Measure #185 (NQF 0659): Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use – National Quality Strategy Domain: Communication and CareCoordination

2017 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY


DESCRIPTION: Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a 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 reported each time a surveillance colonoscopy is performed during the performance period. It is anticipated the eligible clinician who performs the listed procedures, as specified in the denominator coding, will report 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 Reporting: The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

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 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

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)

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OR Denominator Exception: Documentation of medical reason(s) for an interval of

less than 3 years since the last colonoscopy (eg, 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]) (0529F with 1P)

OR Denominator Exception: Documentation of system reason(s) for an interval of

less than 3 years since the last colonoscopy (eg, unable to locate previous colonoscopy report, previous colonoscopy report was incomplete) (0529F with 3P)

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 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 5–10 years; 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). Patients with 3 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 providing that piecemeal removal has not been performed and the adenoma(s) are removed completely; if the follow-up colonoscopy is normal or shows only 1 or 2 small tubular adenomas with low-grade dysplasia, then the interval for the subsequent examination should be 5 years. (Winawer, et al, 2006)

Patients with > 10 adenomas are thought to be at particularly high risk, and current multi-society guidelines therefore recommend early surveillance colonoscopy in these individuals (< 3 years). (Lieberman, et al, 2012) 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)

COPYRIGHT The Measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications.

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The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, eg, use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain.









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2017 Registry Individual Measure Flow #185 NQF #0659: Colonoscopy Interval for Patients with a History of Adenomatous Polyps –

Avoidance of Inappropriate Use Please refer to the specific section of the Measure Specification to identify the denominator and numerator information for use in reporting this Individual Measure.



a. If the Age is greater than or equal to 18 years of age at Date of Service and equals No during the measurement period, do not include in Eligible Patient Population. Stop Processing.

b. If the Age is greater than or equal to 18 years of age at Date of Service and equals Yes during the measurement period, proceed to check Encounter Performed.


a. If Diagnosis for History of Colonic Polyp (s) as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing.

b. If Diagnosis for History of Colonic Polyp (s) as Listed in the Denominator equals Yes, proceed to check Procedure Performed.









7. Start Numerator

8. Check Interval of Three or More Years Since Patient’s Last Colonoscopy:

a. If Interval of Three or More years Since Patient’s Last Colonoscopy equals Yes, include in Data Completeness Met and Performance Met.


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c. If Interval of Three or More Years Since Patient’s Last Colonoscopy equals No, proceed to Interval ofLess Than Three Years Since Patient’s Last Colonoscopy for Medical Reasons.

9. Check Interval of Less Than Three Years Since Patient’s Last Colonoscopy for Medical Reasons:

a. If Interval of Less Than Three Years Since Patient’s Last Colonoscopy for Medical Reasons equals Yes,include in Data Completeness Met and Denominator Exception.


c. If Interval of Less Than Three Years Since Patient’s Last Colonoscopy for Medical Reasons equals No,proceed to Interval of Less Than Three Years Since Patient’s Last Colonoscopy for System Reasons.

10. Check Interval of Less Than Three Years Since Patient’s Last Colonoscopy for System Reasons:

a. If Interval of Less Than Three Years Since Patient’s Last Colonoscopy for System Reasons equals Yes,include in the Data Completeness Met and Denominator Exception.


c. If Interval of Less Than Three Years Since Patient’s Last Colonoscopy for System Reasons equals No,proceed to Interval of Less Than Three Years Since Patient’s Last Colonoscopy, Reason Not Specified.

11. Check Interval of Less Than Three Years Since Patient’s Last Colonoscopy, Reason Not Specified:

a. If Interval of Less Than Three Years Since Patient’s Last Colonoscopy, Reason Not Specified equalsYes, include in Data Completeness Met and Performance Not Met.

b. Data Completeness Met and Performance Not Met letter is represented in the Data Completeness inthe Sample Calculation listed at the end of this document. Letter c equals 2 procedures in the SampleCalculation.

c. If Interval of Less Than Three Years Since Patient’s Last Colonoscopy, Reason Not Specified equalsNo, proceed to Data Completeness Not Met.


a. If Data Completeness Not Met equals No, Quality Data Code or equivalent not reported. 1 procedurehas been subtracted from the data completeness numerator in the sample calculation.

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Measure #425: Photodocumentation of Cecal Intubation – National Quality Strategy Domain: Effective Clinical Care



DESCRIPTION: The rate of screening and surveillance colonoscopies for which photodocumentation of landmarks of cecal intubation is performed to establish a complete examination

INSTRUCTIONS: This measure is to be reported each time a colonoscopy is performed for patients during the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.


DENOMINATOR: Patients for whom a screening or surveillance colonoscopy was performed

Denominator Criteria (Eligible Cases): Patients regardless of age AND Patient procedure during the performance period (CPT or HCPCS): 44388, 44389, 44392, 44394, 44404, 45378, 45380, 45381, 45384, 45385, G0105, G0121 WITHOUT Modifier: 73 or 74

NUMERATOR: Number of patients undergoing screening or surveillance colonoscopy who have photodocumentation of landmarks of cecal intubation to establish a complete examination

NUMERATOR NOTE: In the instance that the patient has an anatomical/physiological reason for not capturing photodocumentation of one or more of cecal landmarks (i.e., patient has no cecum), it would be appropriate to report G9613.

Numerator Quality-Data Coding Options: Documentation of Post-Surgical Anatomy not Capturing Photodocumentation Denominator Exclusion: G9613: Documentation of post-surgical anatomy (e.g., right

hemicolectomy, ileocecal resection, etc.) OR

Photodocumentation of Cecal Intubation Performance Met: G9612: Photodocumentation of one or more cecal landmarks to

establish a complete examination OR

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Photodocumentation of Cecal Intubation not performed, Reason not Otherwise Specified Performance Not Met: G9614: No photodocumentation of cecal landmarks to establish a

complete examination

RATIONALE: It is well supported that visualization of the cecum by notation of landmarks and photodocumentation of landmarks should be documented for every colonoscopy. However, one study of administrative claims data (Baxter et al. 2011) and another of 69 hospital-based endoscopists (Cotton et al. 2003) show variable performance among endoscopists in achieving cecal intubation resulting in complete colonic examination.

The American Society for Gastrointestinal Endoscopy (ASGE)/American College of Gastroenterology (ACG) task force on Quality in Endoscopy, specifically in the paper Quality indicators for colonoscopy, has recommended documenting cecal intubation as a measure of colonoscopic examination completeness. Based on a study of prevalence of proximal colonic polyps in average-risk asymptomatic patients with negative fecal occult blood tests and flexible sigmoidoscopy (Kadakia et al. 1996) it has been well-established that cecal intubation is required as a marker for examination of the entire colon due to the significant number of neoplasms present in the right colon in the absence of positive FOBT or left sided colon neoplasms.

The need for cecal intubation is based on the continual finding that a substantial number of colorectal neoplasms are located in the proximal colon, including the cecum. Numerous studies have shown that physicians routinely do not document the depth of insertion in the colonoscopy report. Quality evaluation of the colon consists of intubation of the entire colon and a detailed mucosal inspection. Cecal intubation improves sensitivity and reduces costs by eliminating the need for radiographic procedures or repeat colonoscopy to complete examination. Careful mucosal inspection is essential to effective colorectal cancer prevention and reduction of cancer mortality.

CLINICAL RECOMMENDATION STATEMENTS: As stated in the Quality indicators for colonoscopy paper developed by the ASGE/ACG task force on Quality in Endoscopy (Rex et al. 2015), “In the United States, colonoscopy is almost always undertaken with the intent to intubate the cecum. Cecal intubation is defined as passage of the colonoscope tip to a point proximal to the ileocecal valve, so that the entire cecal caput, including the medial wall of the cecum between the ileocecal valve and appendiceal orifice, is visible. Cecal intubation should be documented by naming the identified cecal landmarks. Most importantly, these include the appendiceal orifice and the ileocecal valve. For cases in which there is uncertainty as to whether the cecum has been entered, visualization of the lips of the ileocecal valve (ie, the orifice) or intubation of the terminal ileum will be needed.”

Patients who undergo complete colon examination have a lower risk of colorectal cancer than patients with incomplete colonoscopy as was demonstrated in a study of administrative claims data that found endoscopist quality measures were associated with postcolonscopy colorectal cancer (Baxter et al. 2011). The ASGE/ACG task force on Quality in Endoscopy stated effective colonoscopists should be able to intubate the cecum in ≥ 90% of cases, and in ≥ 95% of cases when the indication is screening in a healthy adult. All colonoscopy studies done for screening have reported cecal intubation rates of 97% or higher.

COPYRIGHT: © American College of Gastroenterology, American Gastroenterological Association and American Society for Gastrointestinal Endoscopy, 2015. All rights reserved.

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2017 Claims Individual Measure Flow #425: Photodocumentation of Cecal Intubation





b. If Procedure as Listed in the Denominator equals Yes, proceed to check Modifier: 73 or 74.

3. Check Modifier:

a. If Modifier: 73 or 74 equals No, include in Eligible Population.

b. If Modifier: 73 or 74 equals Yes, do not include in Eligible Patient Population. Stop Processing.



5. Start Numerator

6. Check Documentation of post-surgical anatomy:

a. If Documentation of post-surgical anatomy equals Yes, include in Reporting Data Completeness Met and Performance Exclusion.

b. Data Completeness Met and Denominator Exclusion letter is represented in the Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter x equals 1 procedure in the Sample Calculation.

c. If Documentation of post-surgical anatomy equals No, proceed to Photodocumentation of Cecal Intubation.

7. Check Photodocumentation of One or More Cecal Landmarks to Establish a Complete Examination:

a. If Photodocumentation of One or More Cecal Landmarks to Establish a Complete Examination equals Yes, include in Data Completeness Met and Performance Met.


c. If Photodocumentation of One or More Cecal Landmarks to Establish a Complete Examination equals No, proceed to No Photodocumentation of One or More Cecal Landmarks to Establish a Complete Examination.

8. Check No Photodocumentation of One or More Cecal Landmarks to Establish a Complete Examination:

a. If No Photodocumentation of One or More Cecal Landmarks to Establish a Complete Examination equals Yes, include in Data Completeness Met and Performance Not Met.

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b. Data Completeness Met and Performance Not Met letter is represented in the Data Completeness in the Sample Calculation listed at the end of this document. Letter c equals 2 procedures in the Sample Calculation.

c. If No Photodocumentation of One or More Cecal Landmarks to Establish a Complete Examination equals No, proceed to Data Completeness Not Met.


a. If Data Completeness Not Met equals No, Quality Data Code or equivalent not reported. 1 procedure has been subtracted from the data completeness numerator in the sample calculation.

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Measure #320 (NQF 0658): Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients – National Quality Strategy Domain: Communication and Care Coordination



DESCRIPTION: Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report

INSTRUCTIONS: This measure is to be reported a minimum of once per performance period for patients seen during the performance period. Performance for this measure is not limited to the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on services provided and the measure specific denominator coding. Patients who have a coded colonoscopy procedure that has a modifier 52, 53, 73, or 74 will not qualify for inclusion into the measure.


DENOMINATOR: All patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy


Denominator Criteria (Eligible Cases): Patients aged 50 to 75 on date of encounter AND Patient undergoing screening for malignant neoplasm of colon (ICD-10-CM): Z12.11 AND Patient encounter during the performance period (CPT or HCPCS): 44388, 45378, G0121 WITHOUT Modifiers: 52, 53, 73, or 74

NUMERATOR: Patients who had recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report

Numerator Options Performance Met: Recommended follow-up interval for repeat

colonoscopy of at least 10 years documented in colonoscopy report (0528F)

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OR Denominator Exception: Documentation of medical reason(s) for not

recommending at least a 10 year follow-up interval (e.g., inadequate prep, familial or personal history of colonic polyps, patient had no adenoma and age is ≥ 66 years old, or life expectancy < 10 years old, other medical reasons) (0528F with 1P)

OR Performance Not Met: At least 10 year follow-up interval for colonoscopy not

recommended, reason not otherwise specified (0528F with 8P)

RATIONALE: In the average-risk population, colonoscopy screening is recommended in all current guidelines at 10-year intervals. 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, 2008). The most common serious complication of colonoscopy is post-polypectomy bleeding (Levin et al, 2008).

Variations in the recommended time interval between colonoscopies exist for patients with normal colonoscopy findings. In a 2006 study of 1282 colonoscopy reports, recommendations were consistent with contemporaneous guidelines in only 39.2% of cases and with current guidelines in 36.7% of cases. Further, the adjusted mean number of years in which repeat colonoscopy was recommended was 7.8 years following normal colonoscopy (Krist et al, 2007)

CLINICAL RECOMMENDATION STATEMENTS: At present, CSPY (colonoscopy) every 10 years is an acceptable option for CRC screening in average-risk adults beginning at age 50 years. (ACS/USMSTF/ACR, 2008). The USPSTF recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until the age of 75 years. The risks and benefits of these screening methods vary (Grade A Recommendation) (USPTF, 2008).

The USPSTF recommends against “routine” screening for colorectal cancer in adults 76 to 85 years of age who have been adequately screened. There may be considerations that support colorectal cancer screening in an individual patient (Grade C Recommendation) (USPSTF, 2008).The preferred CRC prevention test is colonoscopy every 10 years, beginning at age 50. (Grade 1B) (Rex, et al, 2009)

COPYRIGHT: The Measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications.

The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain.


The AMA’s, PCPI’s and National Committee for Quality Assurance’s significant past efforts and contributions to the

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development and updating of the Measures is acknowledged. AGA, ASGE and ACG are solely responsible for the review and enhancement (“Maintenance”) of the Measures as of August 14, 2014.







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2017 Registry Individual Measure Flow #320 NQF #0658: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients




a. If the Age is 50 to 75 years of age at Date of Service and equals No during the measurement period, do not include in Eligible Patient Population. Stop Processing.

b. If the Age is 50 to 75 years of age at Date of Service and equals Yes during the measurement period, proceed to check Patient Undergoing Screening for Malignant Neoplasm of Colon.

3. Check Patient Undergoing Screening for Malignant Neoplasm of Colon:

a. If Patient Understanding Screening for Malignant Neoplasm of Colon equals No, do not include in Eligible Patient Population. Stop Processing.

b. If Patient Understanding Screening for Malignant Neoplasm of Colon equals Yes, proceed to check Procedure Performed.



b. If Encounter as Listed in the Denominator equals Yes, proceed to check Modifiers: 52, 53, 73,or 74.





a. Denominator population is all Eligible Patients in the denominator. Denominator is represented as Denominator in the Sample Calculation listed at the end of this document. Letter d equals 8 patients in the sample calculation.

7. Start Numerator

8. Check Recommended Follow-Up Interval for Repeat Colonoscopy of at Least 10 Years and Documented in Colonoscopy Report:

a. If Recommended Follow-Up Interval for Repeat Colonoscopy of at Least 10 Years and Documented in Colonoscopy Report equals Yes, include in Data Completeness Met and Performance Met.

b. Data Completeness Met and Performance Met letter is represented in the Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter a equals 4 patients in the Sample Calculation.

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c. If Recommended Follow-Up Interval for Repeat Colonoscopy of at Least 10 Years and Documented inColonoscopy Report equals No, proceed to Documentation of Medical Reason(s) for notRecommending at Least a 10 Year Follow-up Interval.

9. Check Documentation of Medical Reason(s) for not Recommending at Least a 10 Year Follow-upInterval:

a. If Documentation of Medical Reason(s) for not Recommending at Least a 10 Year Follow-up Intervalequals Yes, include in Data Completeness Met and Performance Exclusion.

b. Data Completeness Met and Denominator Exception is represented in the Data Completeness andPerformance Rate in the Sample Calculation listed at the end of this document. Letter b equals 1 patientin the Sample Calculation.

c. If Documentation of Medical Reason(s) for not Recommending at Least a 10 Year Follow-up Intervalequals No, proceed to At Least 10 Year Follow-Up Interval for Colonoscopy Not Recommended, Reasonnot Specified.

10. Check At Least 10 Year Follow-Up Interval for Colonoscopy Not Recommended, Reason Not Specified:

a. If At Least 10 Year Follow-Up Interval for Colonoscopy Not Recommended, Reason Not Specifiedequals Yes, include in Data Completeness Met and Performance Not Met.

b. Data Completeness Met and Performance Not Met is represented in the Data Completeness in theSample Calculation listed at the end of this document. Letter c equals 2 patients in the SampleCalculation.

c. If At Least 10 Year Follow-Up Interval for Colonoscopy Not Recommended, Reason Not Specifiedequals No, proceed to Data Completeness Not Met.


a. If Data Completeness Not Met equals No, Quality Data Code or equivalent not reported. 1 patient hasbeen subtracted from the Data Completeness numerator in the same calculation.

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Measure #343: Screening Colonoscopy Adenoma Detection Rate – National Quality Strategy Domain: Effective Clinical Care


MEASURE TYPE: Outcome

DESCRIPTION: The percentage of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy

INSTRUCTIONS: This measure is to be reported each time a screening colonoscopy for colorectal cancer is performed during the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.


DENOMINATOR: Patients age 50 years or older undergoing a screening colonoscopy

Definition: Colorectal Cancer Precursor Lesions- Based on pathologic diagnosis, colorectal cancer precursor lesions include: adenomatous polyps [tubular, tubulovillous, villous] and traditional serrated adenomas, sessile serrated polyps and sessile serrated adenomas.

Denominator Criteria (Eligible Cases): Patients 50 years of age or older on date of encounter AND Risk factors for colorectal cancer (ICD-10-CM): Z80.0, Z83.71, Z12.11 AND Patient procedure during performance period (CPT or HCPCS): 45378, 45380, 45381, 45384, 45385, G0121 WITHOUT Modifiers: 52, 53, 73, or 74

NUMERATOR: Number of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy

Numerator Options: Performance Met: Adenoma(s) or other neoplasm detected during screening

colonoscopy (3775F) OR

Denominator Exception: Documentation of reason for not detecting adenoma(s) or other neoplasm (e.g., Neoplasm detected is only diagnosed as traditional serrated adenoma, sessile serrated polyp, or sessile serrated adenoma) (G9496)

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OR Performance Not Met: Adenoma(s) or other neoplasm not detected during

screening colonoscopy (3776F)

RATIONALE: The removal of adenomatous polyps during a screening colonoscopy is associated with a lower risk of subsequent colorectal cancer incidence and mortality. Higher adenoma detection rates (> 25% in a mixed gender population) are associated with significant protection against incident colorectal cancer in the five years following screening colonoscopy.

CLINICAL RECOMMENDATION STATEMENTS: The United States Preventive Services Task Force has recommended screening colonoscopy for adults, beginning at age 50 and continuing until age 75 (Grade A recommendation) Screening exams are those performed to detect lesions in the absence of signs, symptoms, or personal history of colon neoplasia. The adenoma detection rate is an independent predictor of risk of developing colorectal cancer between screening colonoscopies. However, studies have documented wide variation in adenoma detection rates, illustrating the need for measuring and monitoring this metric for endoscopists. Some studies have identified variation due to the location of adenomas. Procedure length has also been found in some, but not all, studies to correlate with adenoma detection rate. The adenoma detection rate varies between genders, with a lower rate demonstrated in women. Multi-specialty and stakeholder guidelines support the importance of measuring the adenoma detection rate in the prevention of colorectal cancer. Guidelines and the supporting literature support performance targets for adenoma detection rate of 25% for a mixed gender population (20% in women and 30% in men). The performance targets for adenoma detection rate were established by using studies reporting detection of conventional adenomas. Serrated lesions are a separate class from conventional adenomas. Sessile serrated polyp/adenoma differentiation from hyperplastic polyp is subject to marked interobserver variation in pathologic interpretation. Thus, serrated lesions should not be counted toward the ADR.


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2017 Registry Individual Measure Flow #343: Screening Colonoscopy Adenoma Detection Rate




a. If Patient Age is greater than or equal to 50 Years of age on Date of Service during performance period equals No, do not include in Eligible Population. Stop Processing.

b. If Patient Age is greater than or equal to 50 Years of age on Date of Service during performance period equals Yes, proceed to check Patient Diagnosis.


a. If Diagnosis for Risk Factors for Colorectal Cancer as Listed in the Denominator equals No, do not include in Eligible Population. Stop Processing.

b. If Diagnosis for Risk Factors for Colorectal Cancer as Listed in the Denominator equals Yes, proceed to check Procedure Performed.


a. If Procedure as Listed in the Denominator equals No, do not include in Eligible Population. Stop Processing.

b. If Procedure as Listed in the Denominator equals Yes, proceed to check Modifiers: 52, 53,73 or 74.

5. Check Modifiers: 52, 53, 73 or 74:

a. If Modifiers: 52, 53, 73 or 74 equals Yes, do not include in Eligible Population. Stop Processing.

b. If Modifiers: 52, 53, 73 or 74 equals No, include in the Eligible population.

6. Denominator Population


7. Start Numerator

8. Check Adenoma(s) or Other Neoplasm Detected During Screening Colonoscopy:

a. If Adenoma(s) or Other Neoplasm Detected During Screening Colonoscopy equals Yes, include in Data Completeness Met and Performance Met.


c. If Adenoma(s) or Other Neoplasm Detected During Screening Colonoscopy equals No, proceed to check Documentation of Reason for not Detecting Adenoma(s) or other Neoplasm.

9. Check Documentation of Reason for not Detecting Adenoma(s) or Other Neoplasm:

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a. If Documentation of Reason for not Detecting Adenoma(s) or Other Neoplasm equals Yes, include in Data Completeness Met and Denominator Exception.

b. Data Completeness Met and Denominator Exception letter is represented in the Data Completeness in the Sample Calculation listed at the end of this document. Letter b equals 5 procedures in the Sample Calculation.

c. If Documentation of Reason for not Detecting Adenoma(s) or Other Neoplasm equals No, proceed to check Adenoma(s) or Other Neoplasm not Detected During Screening Colonoscopy.

10. Check Adenoma(s) or Other Neoplasm not Detected During Screening Colonoscopy:

a. If Adenoma(s) or Other Neoplasm not Detected During Screening Colonoscopy equals Yes, include in Data Completeness Met and Performance Not Met.


c. If Adenoma(s) or Other Neoplasm not Detected During Screening Colonoscopy equals No, proceed to Data Completeness Not Met.

11. Check Data Completeness Not Met

a. If Data Completeness Not Met, the Quality Data Code or equivalent was not reported. 1 procedure has been subtracted from the Data Completeness numerator in sample calculation.

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Measure #425: Photodocumentation of Cecal Intubation – National Quality Strategy Domain: Effective Clinical Care



DESCRIPTION: The rate of screening and surveillance colonoscopies for which photodocumentation of landmarks of cecal intubation is performed to establish a complete examination

INSTRUCTIONS: This measure is to be reported each time a colonoscopy is performed for patients during the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.


DENOMINATOR: Patients for whom a screening or surveillance colonoscopy was performed

Denominator Criteria (Eligible Cases): Patients regardless of age AND Patient procedure during the performance period (CPT or HCPCS): 44388, 44389, 44392, 44394, 44404, 45378, 45380, 45381, 45384, 45385, G0105, G0121 WITHOUT Modifier: 73 or 74 AND NOT DENOMINATOR EXCLUSION: Documentation of post-surgical anatomy (e.g., right hemicolectomy, ileocecal resection, etc.): G9613

NUMERATOR: Number of patients undergoing screening or surveillance colonoscopy who have photodocumentation of landmarks of cecal intubation to establish a complete examination

Numerator Options: Performance Met: Photodocumentation of one or more cecal landmarks

to establish a complete examination (G9612) OR

Performance Not Met: No photodocumentation of cecal landmarks to establish a complete examination (G9614)

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RATIONALE: It is well supported that visualization of the cecum by notation of landmarks and photodocumentation of landmarks should be documented for every colonoscopy. However, one study of administrative claims data (Baxter et al. 2011) and another of 69 hospital-based endoscopists (Cotton et al. 2003) show variable performance among endoscopists in achieving cecal intubation resulting in complete colonic examination.

The American Society for Gastrointestinal Endoscopy (ASGE)/American College of Gastroenterology (ACG) task force on Quality in Endoscopy, specifically in the paper Quality indicators for colonoscopy, has recommended documenting cecal intubation as a measure of colonoscopic examination completeness. Based on a study of prevalence of proximal colonic polyps in average-risk asymptomatic patients with negative fecal occult blood tests and flexible sigmoidoscopy (Kadakia et al. 1996) it has been well-established that cecal intubation is required as a marker for examination of the entire colon due to the significant number of neoplasms present in the right colon in the absence of positive FOBT or left sided colon neoplasms.

The need for cecal intubation is based on the continual finding that a substantial number of colorectal neoplasms are located in the proximal colon, including the cecum. Numerous studies have shown that physicians routinely do not document the depth of insertion in the colonoscopy report. Quality evaluation of the colon consists of intubation of the entire colon and a detailed mucosal inspection. Cecal intubation improves sensitivity and reduces costs by eliminating the need for radiographic procedures or repeat colonoscopy to complete examination. Careful mucosal inspection is essential to effective colorectal cancer prevention and reduction of cancer mortality.

CLINICAL RECOMMENDATION STATEMENTS: As stated in the Quality indicators for colonoscopy paper developed by the ASGE/ACG task force on Quality in Endoscopy (Rex et al. 2015), “In the United States, colonoscopy is almost always undertaken with the intent to intubate the cecum. Cecal intubation is defined as passage of the colonoscope tip to a point proximal to the ileocecal valve, so that the entire cecal caput, including the medial wall of the cecum between the ileocecal valve and appendiceal orifice, is visible. Cecal intubation should be documented by naming the identified cecal landmarks. Most importantly, these include the appendiceal orifice and the ileocecal valve. For cases in which there is uncertainty as to whether the cecum has been entered, visualization of the lips of the ileocecal valve (ie, the orifice) or intubation of the terminal ileum will be needed.”

Patients who undergo complete colon examination have a lower risk of colorectal cancer than patients with incomplete colonoscopy as was demonstrated in a study of administrative claims data that found endoscopist quality measures were associated with postcolonscopy colorectal cancer (Baxter et al. 2011). The ASGE/ACG task force on Quality in Endoscopy stated effective colonoscopists should be able to intubate the cecum in ≥ 90% of cases, and in ≥ 95% of cases when the indication is screening in a healthy adult. All colonoscopy studies done for screening have reported cecal intubation rates of 97% or higher.


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2017 Registry Individual Measure Flow #425: Photodocumentation of Cecal Intubation




a. If Procedure as Listed in the Denominator equals No, do not include in Eligible Patient Population. StopProcessing.

b. If Procedure as Listed in the Denominator equals Yes, proceed to check Modifier: 73 or 74.

3. Check Modifier:

a. If Modifier: 73 or 74 equals No, do not include in Eligible Patient Population. Stop Processing.

b. If Modifier: 73 or 74 equals Yes, proceed to Denominator Exclusion.

4. Check Denominator Exclusion:

a. If Denominator Exclusion, Documentation of Post-Surgical anatomy equals Yes, do not include inEligible Patient Population. Stop Processing.

b. If Denominator Exclusion, Documentation of Post-Surgical anatomy equals No, include in EligiblePatient Population.


a. Denominator population is all Eligible Patients in the denominator. Denominator is represented asDenominator in the Sample Calculation listed at the end of this document. Letter d equals 8 proceduresin the sample calculation.

6. Start Numerator

7. Check Photodocumentation of One or More Cecal Landmarks to Establish a Complete Examination:

a. If Photodocumentation of One or More Cecal Landmarks to Establish a Complete Examination equalsYes, include in Data Completeness Met and Performance Met.

b. Data Completeness and Performance Met letter is represented in the Data Completeness Met andPerformance Rate in the Sample Calculation listed at the end of this document. Letter a equals 5procedures in the Sample Calculation.

c. If Photodocumentation of One or More Cecal Landmarks to Establish a Complete Examination equalsNo, proceed to Photodocumentation of Cecal Intubation Not Performed.

8. Check No Photodocumentation of One or More Cecal Landmarks to Establish a Complete Examination:

a. If No Photodocumentation of One or More Cecal Landmarks to Establish a Complete Examinationequals Yes, include in Data Completeness Met and Performance Not Met.

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c. If No Photodocumentation of One or More Cecal Landmarks to Establish a Complete Examination equals No, proceed to Data Completeness Not Met.


a. If Data Completeness Not Met equals No, Quality Data Code or equivalent not reported. 1 procedure has been subtracted from the data completeness numerator in the sample calculation.

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Measure #439: Age Appropriate Screening Colonoscopy – National Quality Strategy Domain: Efficiency and Cost Reduction


MEASURE TYPE: Efficiency

DESCRIPTION: The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31

INSTRUCTIONS: This measure is to be reported each time a colonoscopy is performed for all patients during the performance period. There is no diagnosis associated with this measure. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.


DENOMINATOR: Colonoscopy examinations performed on patients greater than 85 years of age during the encounter period

Denominator Instructions: 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 forinclusion in this measure.

Denominator Criteria (Eligible Cases): All patients greater than 85 years of age on date on encounter receiving a colonoscopy for screening purposes only AND Patient encounter during the performance period (CPT or HCPCS): 45378, 45380, 45381, 45384, 45385, G0121 WITHOUT Modifier: 52, 53, 73, or 74

NUMERATOR: All patients greater than 85 years of age included in the denominator who did NOT have a history of colorectal cancer or a valid medical reason for the colonoscopy, including: iron deficiency anemia, lower gastrointestinal bleeding, Crohn’s Disease (i.e. regional enteritis), familial adenomatous polyposis, Lynch Syndrome (i.e., hereditary non- polyposis colorectal cancer), inflammatory bowel disease, ulcerative colitis, abnormal findings of gastrointestinal tract, or changes in bowel habits. Colonoscopy examinations performed for screening purposes only

Numerator Instructions: INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Reporting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures a rate of 100% means all of the denominator eligible patients

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did not receive the appropriate care or were not in proper control.

Numerator Options: Performance Met: Patients greater than 85 years of age who did not have a

history of colorectal cancer or valid medical reason for the colonoscopy, including: iron deficiency anemia, lower gastrointestinal bleeding, Crohn’s Disease (i.e., regional enteritis), familial adenomatous polyposis, Lynch Syndrome (i.e., hereditary non-polyposis colorectal cancer), inflammatory bowel disease, ulcerative colitis, abnormal finding of gastrointestinal tract, or changes in bowel habits (G9659)

OR Performance Not Met: Documentation of medical reason(s) for a colonoscopy

performed on a patient greater than 85 years of age (e.g., last colonoscopy incomplete, last colonoscopy had inadequate prep, iron deficiency anemia, lower gastrointestinal bleeding, Crohn’s Disease (i.e., regional enteritis), familial history of adenomatous polyposis, Lynch Syndrome (i.e., hereditary non-polyposis colorectal cancer), inflammatory bowel disease, ulcerative colitis, abnormal finding of gastrointestinal tract, or changes in bowel habits) (G9660)

OR Performance Not Met: Patients greater than 85 years of age who received a

routine colonoscopy for a reason other than the following: an assessment of signs/symptoms of GI tract illness, and/or the patient is considered high risk, and/or to follow-up on previously diagnoses advance lesions (G9661)

RATIONALE: The benefit of colorectal cancer screening for an individual patient is dependent on that patient’s life expectancy and probability of harm from colonoscopy. Individuals over age 85 have an average life expectancy of less than 5 years [Cho Ann Intern Med. 2013;59:667-676] and are at increased risk for colonoscopy-related complications [Ann Intern Med. 2009;150:849-857].

The population of individuals 85 years and older is projected to double by 2050, hence, the clinical and economic effects of inappropriate performance of colorectal cancer screening in this age group can be expected to increase in the coming decade (Goodwin, 2011).

CLINICAL RECOMMENDATION STATEMENTS: The USPSTF (2008) recommends three screening regimens for individuals 50-75 years of age with average risk:

• Annual high-sensitivity FOBT.• Sigmoidoscopy every 5 years, combined with high-sensitivity fecal occult blood testing every 3 years.• Optical colonoscopy every 10 years

For individuals from 76–85 years of age, the Task Force recommends against routine performance of screening unless individuals have not been previously screened, in which case it should be considered in the context of health status and competing risks for each individual (USPSTF, 2008).For individuals older than 85 years, the Task Force recommends against screening when comparing overall benefits to harms (D Recommendation) (USPSTF, 2008). The Task Force

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based these recommendations on a systematic review of the literature, supplemented with modeling data (USPSTF, 2008; NCI 2013; USCR, 2011).

For this subgroup, the Task Force concluded that the utility of screening is limited, given the time it takes for a polyp to develop into a clinically observable malignancy (10–26 years) (USPSTF, 2008; NCI 2013; USCR, 2011).

Moreover, individuals older than 85 are likely to have multiple comorbidities that influence any potential life-year gain (USPSTF, 2008; NCI 2013; USCR, 2011). They are also at increased risk of suffering from adverse events related to performance of a colonoscopy, with the rate of adverse events being 2.8 per 1,000 procedures and increased by seven-fold if a polypectomy is performed (USPSTF, 2008; CDC 2012; NCI, 2013).


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2017 Registry Individual Measure Flow #439: Unnecessary Screening Colonoscopy in Older Adults




a. If the Age is greater than 85 years of age on Date of Service and equals No during the measurement period, do not include in Eligible Patient Population. Stop Processing.

b. If the Age is greater than 85 years of age on Date of Service and equals Yes during the measurement period, proceed to check Patient Procedure.



b. If Procedure as Listed in the Denominator equals Yes, include in Eligible Population.



5. Start Numerator

6. Check Patients Greater Than 85 Years of Age Who Did Not Have a History of Colorectal Cancer or Valid Medical Reason for the Colonoscopy:

a. If Patients Greater Than 85 Years of Age Who Did Not Have a History of Colorectal Cancer or Valid Medical Reason for the Colonoscopy equals Yes, include in Data Completeness Met and Performance Met.

b. Data Completeness Met and Performance Met is represented as Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter a equals 3 procedures in Sample Calculation.

c. If Patients Greater Than 85 Years of Age Who Did Not Have a History of Colorectal Cancer or Valid Medical Reason for the Colonoscopy equals No, proceed to Documentation of Medical Reason(s) for a Colonoscopy Performed on a Patient Greater Than 85 Years of Age:

7. Check Documentation of Medical Reason(s) for a Colonoscopy Performed on a Patient Greater Than 85 Years of Age:

a. If Documentation of Medical Reason(s) for a Colonoscopy Performed on a Patient Greater Than 85 Years of Age equals Yes, include in Data Completeness Met and Performance Not Met.

b. Data Completeness Met and Performance Not Met is represented as Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter c1 equals 2 procedures in the Sample Calculation.

Version 1.0 11/15/2016


c. If Documentation of Medical Reason(s) for a Colonoscopy Performed on a Patient Greater Than 85 Years of Age equals No, proceed to Patients Greater Than 85 Years of Age Who Received a Routine Colonoscopy for a Reason Other Than the Following: An Assessment of Signs/Symptoms of GI Tract Illness, and/or the Patient is Considered High Risk, and/or to Follow-up on Previously Diagnoses Advance Lesions.

8. Check Patients Greater Than 85 Years of Age Who Received a Routine Colonoscopy for a Reason Other Than the Following: An Assessment of Signs/Symptoms of GI Tract Illness, and/or the Patient is Considered High Risk, and/or to Follow-up on Previously Diagnoses Advance Lesions:

a. If Patients Greater Than 85 Years of Age Who Received a Routine Colonoscopy for a Reason Other Than the Following: An Assessment of Signs/Symptoms of GI Tract Illness, and/or the Patient is Considered High Risk, and/or to Follow-up on Previously Diagnoses Advance Lesions equals Yes, include in Data Completeness Met and Performance Not Met.

b. Data Completeness Met and Performance Not Met is represented as Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter c2 equals 2 procedures in the Sample Calculation.

c. Patients Greater Than 85 Years of Age Who Received a Routine Colonoscopy for a Reason Other Than the Following: An Assessment of Signs/Symptoms of GI Tract Illness, and/or the Patient is Considered High Risk, and/or to Follow-up on Previously Diagnoses Advance Lesions equals No, proceed to Data Completeness Not Met.


a. If Data Completeness Not Met equals No, Quality Data Code or equivalent not reported. 1 procedure has been subtracted from the data completeness numerator in sample calculation.

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ASCQR Specifications Manual

Encounter dates 01-01-17 (1Q17) through 12-31-17 (4Q17) v6.0a

CPT® only copyright 2016 American Medical Association. All rights reserved. 1-18

Material inside brackets ([and]) is new to this Specifications Manual version.

Measure Information Form

Measure Title: Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in

Average Risk Patients

Measure ID #: ASC-9

Quality Reporting Option: [Measures submitted via a web-based tool]

Description: Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without

biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat

colonoscopy documented in their colonoscopy report

Numerator Statement: Patients who had a recommended follow-up interval of at least 10 years for repeat

colonoscopy documented in their colonoscopy report

Denominator Statement: All patients aged 50 to 75 years of age receiving screening colonoscopy without

biopsy or polypectomy

Denominator Criteria (Eligible Cases):

Patients aged ≥ 50 and ≤ 75 on date of encounter

and

ICD-10-CM Diagnosis code: Z12.11

and

CPT or HCPCS: 44388, 45378, G0121

without CPT Category I Modifiers: 52, 53, 73, 74

without

ICD-10-CM Diagnosis codes: Z83.71, Z86.010, Z80.0, Z85.038

Denominator Exclusions:

Documentation of medical reason(s) for not recommending at least a 10 year follow-up interval (e.g.,

above average risk, inadequate prep). Medical reason(s) are at the discretion of the physician.

Documentation indicating no follow-up colonoscopy is needed or recommended is only acceptable if the

patient’s age is documented as the reason. Documentation of a medical condition or finding can be used

as a medical reason(s) for denominator exclusion purposes only if the documented recommended follow-

up interval is less than 10 years.

Examples:

Diverticulitis documented in the medical record and a follow-up interval of 5 years in the

colonoscopy report.

Family history of colon cancer and a follow-up interval of 3 years documented in the

colonoscopy report.

Less than adequate prep documented in the medical record with a repeat colonoscopy in 3

years in the colonoscopy report.

Annual Data Submission Period: See the timeline posted to QualityNet.org for this measure; select ASCs

and then Data Submission in the drop-down menu. Data entry will be achieved through the secure side of

QualityNet.org via an online tool available to authorized users.

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Additional Instructions: Patients will be counted in the numerator if there is reference in the final

colonoscopy report that the appropriate follow-up interval for the repeat colonoscopy is at least 10 years

from the date of the current colonoscopy (i.e., the colonoscopy performed during the measurement period). A

range that includes “10 years” (e.g., 7 to 10 years) is not acceptable.




Material inside brackets ([and]) is new to this Specifications Manual version.

Measure Information Form

Measure Title: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of

Adenomatous Polyps – Avoidance of Inappropriate Use

Measure ID #: ASC-10

Quality Reporting Option: [Measures submitted via a web-based tool]

Description: Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a

history of a prior colonic polyp(s) in previous colonoscopy findings, who had a follow-up interval of 3 or

more years since their last colonoscopy

Numerator Statement: Patients who had an interval of 3 or more years since their last colonoscopy

Denominator Statement: All patients aged 18 years and older receiving a surveillance colonoscopy with a

history of a prior colonic polyp(s) in previous colonoscopy findings

Denominator Criteria (Eligible Cases): Patients aged ≥ 18 years on date of encounter

and

Diagnosis for history of colonic polyp(s) (ICD-10-CM): Z86.010

and

CPT or HCPCS: 44388, 44389, 44392, 44394, 45378, 45380, 45381, 45384, 45385, G0105

without

CPT Category I Modifiers: 52, 53, 73, or 74

Denominator Exclusions:

Documentation of medical reason(s) for an interval of less than 3 years since the last colonoscopy (e.g.,

patients with high risk for colon cancer, last colonoscopy incomplete, last colonoscopy had inadequate prep,

piecemeal removal of adenomas/polyps, or last colonoscopy found greater than 10 adenomas/polyps).

Medical reason(s) are at the discretion of the physician. “History of colonic polyps” is not an acceptable

reason to exclude cases from the denominator. A patient must have a history of colonic polyps to be eligible

for the measure. Documentation of a medical condition or finding can be used as a medical reason(s) for

denominator exclusion purposes only if the previous colonoscopy was less than 3 years prior.

Documentation of system reason(s) clearly documented in the current medical record for an interval of less

than 3 years since the last colonoscopy (e.g., unable to locate previous colonoscopy report). For a system

reason all of the following must be present in the medical record.

The interval since the last colonoscopy is less than 3 years; and

A medical reason for an interval of less than 3 years is not documented; and

A “system reason” is documented (e.g., previous colonoscopy report not available, unable to locate

last colonoscopy report).

Annual Data Submission Period: See the timeline posted to QualityNet.org for this measure; select ASCs

and then Data Submission in the drop-down menu. Data entry will be achieved through the secure side of

QualityNet.org via an online tool available to authorized users.

Additional Instructions: For the purpose of this measure, a surveillance colonoscopy is defined as the

colonoscopy performed after a colonic polyp(s) has been detected and removed. The denominator of this

measure is the total number of patients ≥ 18 years of age receiving a surveillance colonoscopy. The

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numerator is the number of patients receiving a surveillance colonoscopy 3 years or greater after the

colonoscopy showing the colonic polyp. Information regarding the performance interval can be obtained

from medical record documentation.

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