CMS 130 Colorectal Cancer Screening

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Overview

This measure reports the percentage of patients 50-75 years old who received the appropriate colorectal cancer screening. The screening may have been an FOBT, sigmoidoscopy, colonoscopy, FIT DNA, or CT Colonography. The time frame for when the screening must have occurred depends on the screening type used.

At a Glance

eMeasure ID	CMS130v8
NQF	N/A
Used For?	Medicaid PI/Stage 3, MIPS (Quality)
Domain	Effective Clinical Care
MIPS Quality ID	113
MIPS Measure Type	Process
MIPS High Priority?	No

Measure Specification and Value Sets

You should be familiar with this measure’s specification, Value Sets, and direct reference codes (if applicable). Refer to Downloading Measure Specifications and Value Sets for more information. Measure help now includes hyperlinks to the Value Sets used by this measure. You must be registered for a UMLS license and signed in to your account to see this content.

Identifying Event Times

See Identifying Event Times for important information about the logic this dashboard uses.

Amending Signed Notes

As a best practice, Notes should not be signed until they are finalized. Amending a signed Note (by making changes to it in Prime Suite and then re-saving it) will change a patient’s qualification for this measure. Re-signing the amended Note may allow the patient to qualify again, but only if it is re-signed during the time period required by the measure.

Documenting Recorded Medications in Prime Mobile

If using Prime Mobile to document a recorded medication, you must enter a non-zero duration. Entering a duration ensures the medication's end date calculates properly and that the medication can qualify for eCQMs. Otherwise, Prime Mobile defaults the medication's end date to midnight of the date recorded. Since this can cause the medication’s end date and time to occur before its start date and time, the medication would not count towards any eCQMs looking for active medications.

Measure Calculations

Initial Population	Patients 50-75 years of age with a visit during the measurement period.
Denominator	Initial Patient Population
Numerator	Patients with one or more of the following colorectal cancer screenings: Fecal occult blood test (FOBT) during the measurement period Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period start date Colonoscopy during the measurement period or the nine years prior to the measurement period start date FIT-DNA during the measurement period or the two years prior to the measurement period start date CT Colonography during the measurement period or the four years prior to the measurement period start date

Measure Details

Initial Population/Denominator

Patients are counted in the denominator if they meet each of the following:

1.

They were 50-74 years old at the beginning of the measurement period. Patients who turn 75 years old during the measurement period will qualify. Patients who turn 76 during the measurement period will not qualify. Age is based on the date of birth (DOB) entered on the patient's Information page.

2.

They had at least one non-voided face-to-face encounter during the measurement period. This must be documented in the Plan or E&M section of a Note using a code from one of the following Value Sets:

• Annual Wellness Visit
• Home Healthcare Services
• Office Visit
• Preventative Care Services - Established Office Visit, 18 and Up
• Preventative Care Services - Initial Office Visit, 18 and Up

Denominator Exclusions

Patients will be excluded from the denominator if they meet any of the following. Select a link for additional information.

• They received hospice care during the measurement period.
• They have a diagnosis or past history of total colectomy or colorectal cancer.
• They were in long term care.
• They had an advanced illness and frailty.

When documenting in Past Medical History (PMHx), Past Surgical History (PSHx), or the Problem List, a Date of Onset should be entered using the mm/dd/yyyyy format. For PMHx and PSHx, use Code Mapper to ensure that the term you’re using has been mapped to a code from the correct Value Set (Chart > Vocab Admin > Code Mapper > select section).

Hospice Care

Patients who received hospice care will be excluded from the denominator. This can be indicated by any of the following:

• They were discharged from the hospital into hospice care during the measurement period. This must be documented with a vocabulary term using a parent code from the Encounter Inpatient Value Set and a child code using either of the following SNOMEDCT version 2019-05-10 direct reference codes:
  • 428371000124100 indicating a patient was Discharged to a health care facility for hospice care.
  • 428361000124107 indicating a patient was Discharged to home for hospice care.
• They received hospice care. This must be documented with a vocabulary term in a Flowsheet using a code from the Hospice care ambulatory Value Set. The date the provider enters this documentation must occur during the measurement period.
• They had an order for hospice care. This must be documented in the Plan or Results section of a Note using a code from the Hospice care ambulatory Value Set. This order must have been created during the measurement period.

Diagnosis or Past History of Total Colectomy or Colorectal Cancer

Patients who have a diagnosis or past history of total colectomy or colorectal cancer will be excluded from the denominator. This can be indicated by either of the following:

• They were diagnosed with malignant neoplasm of the colon at any point in time prior to the measurement period end date. This must be documented using a code from the Malignant Neoplasm of Colon Value Set. This can be indicated any of the following:
  • A diagnosis documented in the Assessment section of a Note.
  • An active diagnosis documented in Past Medical History (PMHx) on the Facesheet. The diagnosis must be documented with a valid onset date. Note that if the diagnosis is entered in Past Medical History (PMHx), the diagnosis will remain in the patient's history indefinitely. The only way to end the diagnosis is to add it through the Problem List and enter a resolved date or inactivate it.
  • An active, resolved, or inactive diagnosis documented on the Problem List. The diagnosis must be documented with a valid onset date. If resolved, the diagnosis must also have a valid resolved date.
  • A vocabulary term in the Results or in a Flowsheet

• They had a total colectomy at any point in time prior to the measurement period end date. This must be documented using a code from the Total Colectomy Value Set. This documentation can be made in any of the following:
  • Orders Tracking History (with a status of Returned or Reviewed)
  • Past Surgical History (PSHx)
  • as a vocabulary term in the Results or in a Flowsheet

Long Term Care

Patients who spent more than 90 days cumulatively in long term care during the measurement period will be excluded from the denominator. They must meet each of the following:

1.

They were 65 years old or older at the beginning of the measurement period, based on the date of birth (DOB) entered on the Information page.

2.

They spent more than 90 cumulative days in a long-term care facility during the measurement period, documented with an encounter. This encounter can be documented in a clinical note linked to a single day visit for each day the patient was in the long-term care facility or a clinical note linked to a multi-day visit. A single day visit must have a duration of 24 hours or greater to qualify. This means that the visit's end date must not occur less than 24 hours after the visit's start date. The encounter must be documented using codes from either of the following Value Sets:

• Care Services in a Long-Term Residential Facility
• Nursing Facility Visit

Advanced Illness and Frailty

Patients with advanced illness and frailty during the measurement period will be excluded from the denominator. This must be indicated by each of the following:

1.

They were 65 years old or older at the beginning of the measurement period, based on the date of birth (DOB) entered on the Information page.

2.

They had a device, diagnosis, or symptoms of frailty. This must be indicated by any of the following:

• An order for a device related to frailty created during the measurement period, documented in the Plan section of a Note, using codes from the Frailty Device Value Set.
• A device related to frailty was applied that overlapped the measurement period. This device must be documented in the Frailty widget, using codes from the Frailty Device Value Set.
• A diagnosis of frailty that overlapped the measurement period. This diagnosis must be documented using a code from the Frailty Diagnosis Value Set. This can be indicated by either of the following:
  • An active diagnosis documented in Past Medical History (PMHx) on the Facesheet. The diagnosis must be documented with a valid onset date. Note that if the diagnosis is entered in Past Medical History (PMHx), the diagnosis will remain in the patient’s history indefinitely. The only way to end the diagnosis is to add it through the Problem List and enter a resolved date or inactivate it.
  • An active, resolved, or inactive diagnosis on the Problem List. The diagnosis must be documented with a valid onset date. If resolved, the diagnosis must also have a valid resolved date.
• A frailty encounter that overlapped the measurement period, documented in the Plan or E&M section of a Note, using a code from the Frailty Encounter Value Set.
• A symptom of frailty that overlapped the measurement period, documented in the Frailty widget, using codes from the Frailty Symptom Value Set. They symptom must be documented with a valid onset date. If resolved, the symptom must also have a valid resolved date.

To overlap the measurement period, one of the following must be true: either its start date and time or end date and time occurred during the measurement period, both its start date and time and end date and time occurred during the measurement period, or its start date and time occurred before the beginning of the measurement period and its end date and time occurred after the end of the measurement period.

3.

They meet one of the following:

• They had two outpatient encounters for advanced illness. These encounters must meet each of the following:

a.

Each encounter must begin two years or less before the end of the measurement period.

b.

Each encounter must be documented in the Plan or E&M section of a Note, using a code from one of the following Value Sets:

• ED
• Nonacute Patient
• Observation
• Outpatient

c.

Each encounter must include a diagnosis of advanced illness documented using a code from the Advanced Illness Value Set.

• They had one inpatient encounter for advanced illness. This encounter must meet each of the following:

a.

The encounter began two years or less before the end of the measurement period.

b.

This encounter must be documented in the Plan or E&M section of a Note, using a code from the Acute Inpatient Value Set.

c.

The encounter must include a diagnosis of advanced illness documented using a code from the Advanced Illness Value Set.

• They had a prescription for a dementia medication that overlapped the measurement period or the year prior to the measurement period. This means that one of the following must be true: either its start date and time or end date and time occurred during the measurement period or the year prior to the measurement period, both its start date and time and end date and time occurred during the measurement period or the year prior to the measurement period, or its start date and time occurred before the beginning of the year prior to the measurement period and its end date and time occurred after the end of the measurement period. This can be documented in the Medication List as either a prescribed medication or recorded medication, using codes from the Dementia Medications Value Set.

Numerator

The numerator consists of patients with any of the following colorectal cancer screenings:

Lab Tests

The following lab tests can qualify patients for the numerator:

• Fecal occult blood test (FOBT) during the measurement period. This must be documented with a vocabulary term using a code from the Fecal Occult Blood Test (FOBT) Value Set.
• FIT-DNA lab test during the measurement period or the two years prior to the measurement period end date. This must be documented with a vocabulary term using a code from the FIT DNA Value Set.

These lab tests must be documented in the Results or a Flowsheet.

Procedures

The following procedures can qualify patients for the numerator.

These procedures must include a Procedure Date. If no Procedure Date is entered for these procedures, they will not be considered for the dashboard. The date the procedures were entered into Prime Suite will not be used.

• Flexible sigmoidoscopy procedure during the measurement period or the four years prior to the measurement period end date. This must be documented using a code from the Flexible Sigmoidoscopy Value Set.
• Colonoscopy during the measurement period or the nine years prior to the measurement period end date. This must be documented using a code from the Colonoscopy Value Set.
• CT colonography during the measurement period or the four years prior to the measurement period end date. This must be documented using a code from the CT Colonography Value Set.

The CT Colonography Value Set was updated for the 2020 reporting year and now only includes LOINC codes. Because of this update, you must map the term you’re using to indicate a CT colonography procedure to a qualifying LOINC code in Vocab Admin. The vocabulary term must documented in the Results or a Flowsheet to receive numerator credit. Previously, a CT colonography procedure had to be documented using a CPT or SNOMED code to receive numerator credit.

Qualifying procedures can be documented in any of the following:

• Orders Tracking History (with a status of Returned or Reviewed)
• With a vocabulary term in the Results or in a Flowsheet
• Past Surgical History (PSHx)

When documenting in Past Surgical History (PSHx), a Date of Onset should be entered using the mm/dd/yyyyy format. Use Code Mapper to ensure that the term you’re using has been mapped to a code from the correct Value Set (Chart > Vocab Admin > Code Mapper > PSHx).

Numerator Exclusions

Not applicable

Denominator Exception

None