CMS 130 - Colorectal Cancer Screening

Overview

CMS130v8 (2020)
CMS130v9 (2021)
CMS130v10 (2022)

Identifiers

CMS eCQM ID	NQF eCQM ID	NQF	MIPS Quality ID
CMS130v10	–	0034	113

*MIE only supports data collection and reporting using eCQM specifications

Definitions

Description	Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer
Initial Patient Population	Patients 50-75 years of age with a visit during the measurement period
Denominator	Equals Initial Population
Denominator Exclusions	Exclude patients who are in hospice care for any part of the measurement period. Exclude patients with a diagnosis or past history of total colectomy or colorectal cancer. Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period. Exclude patients 66 and older with an indication of frailty for any part of the measurement period who meet any of the following criteria: Advanced illness with two outpatient encounters during the measurement period or the year prior Advanced illness with one inpatient encounter during the measurement period or the year prior Taking dementia medications during the measurement period or the year prior Exclude patients receiving palliative care during the measurement period.
Numerator	Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria: Fecal occult blood test (FOBT) during the measurement period Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period Colonoscopy during the measurement period or the nine years prior to the measurement period FIT-DNA during the measurement period or the two years prior to the measurement period CT Colonography during the measurement period or the four years prior to the measurement period
Numerator Exclusions	–
Denominator Exceptions	–

Additional Information

Measure Type	Process measure
Measure Scoring	Proportion measure
Granularity	Patient
Improvement Notation	Higher score indicates better quality
Domain	Effective Clinical Care

Clinical Instructions

New UI Visit Encounter (valid RC202109+)

Original Visit Encounter

Ensure patients aged 50-75 are screened for colorectal cancer. Use the Past Procedures section of the encounter to record a previous Fecal Occult Blood Test (FOBT), Flexible Sigmoidoscopy, Colonoscopy Screening, FIT-DNA, or CT Colonography; otherwise, use the Visit Orders section of the encounter to order/perform one of the recognized procedures at the time of the encounter.

1. While documenting the Visit encounter, either record the previous procedure or the receipt of the colorectal screening, or order and perform the screening, as appropriate:

   1. Option 1: Document in the Past Procedures section

      1. Open the Past Procedures section.
      2. Using the Procedure autocomplete, begin typing the name of the diagnostic procedure (e.g., Colonoscopy) with the appropriate Concept ID.
      3. Add the Date and any relevant Notes.
      4. Click the Next button, or close the section.

   2. Option 2: Document in the Preventive Care section 

      1. Open the Preventive Care section.
      2. Provide the date of the last reported procedure in the Enter New Date field (e.g., 01-17-2019). This date is the Last Reported Date.
      3. Click the Next button, or close the section.

   3. Option 3: Document in the Tests and Procedures section IF performing the screening in-house

      1. Open the Tests and Procedures section.
      2. Using the autocomplete, begin typing the appropriate procedure name.
      3. Click the Add to Exam button.
      4. After adding the new section, open the procedure section and add any results or findings.
      5. Click the Next button, or close the section.

2. Continue documenting the encounter, as needed.

3. When completed, Close and Archive the encounter.

• Option 4: Scan/Index or Upload an accepted screening document
  • Using WebScan , scan and index the appropriate document type configured with the necessary LOIN-C.
    • Scan/Index or Upload the Colonoscopy Screening document type (COLON) configured with the necessary Concept ID (73761001).
    • Scan/Index or Upload the Fecal Occult Blood Test document type (FOBT) configured with the necessary LOIN-C (2335-8); otherwise, add the FOBT observation and ensure it is configured with the 2335-8 LOIN-C.
    • Scan/Index or Upload the Flexible Sigmoidoscopy document type (FLEXSIG) configured with the necessary Concept ID (44441009).
    • Scan/Index or Upload the Computed Tomographic Colongraphy document type (CTC) configured with the necessary Concept ID (418714002).
    • Add the Fit DNA observation to the chart either manually, or via an established interface, and ensure the observation is configured with the 77354-9 LOIN-C.

Evidence

Initial Patient Population

Name	Value Set
Encounter, Performed: Annual Wellness Visit	2.16.840.1.113883.3.526.3.1240
Encounter, Performed: Home Healthcare Services	2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed: Office Visit	2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed: Online Assessments	2.16.840.1.113883.3.464.1003.101.12.1089
Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up	2.16.840.1.113883.3.464.1003.101.12.1025
Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up	2.16.840.1.113883.3.464.1003.101.12.1023
Encounter, Performed: Telephone Visits	2.16.840.1.113883.3.464.1003.101.12.1080

Denominator Exclusions

Name	Value Set
Assessment, Performed: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)	LOINC Code 71007-9
Device, Applied: Frailty Device	2.16.840.1.113883.3.464.1003.118.12.1300
Device, Order: Frailty Device	2.16.840.1.113883.3.464.1003.118.12.1300
Diagnosis: Frailty Diagnosis	2.16.840.1.113883.3.464.1003.113.12.1074
Diagnosis: Malignant Neoplasm of Colon	2.16.840.1.113883.3.464.1003.108.12.1001
Encounter, Performed: Acute Inpatient	2.16.840.1.113883.3.464.1003.101.12.1083
Encounter, Performed: Care Services in Long-Term Residential Facility	2.16.840.1.113883.3.464.1003.101.12.1014
Encounter, Performed: Emergency Department Visit	2.16.840.1.113883.3.464.1003.101.12.1010
Encounter, Performed: Encounter Inpatient	2.16.840.1.113883.3.666.5.307
Encounter, Performed: Frailty Encounter	2.16.840.1.113883.3.464.1003.101.12.1088
Encounter, Performed: Nonacute Inpatient	2.16.840.1.113883.3.464.1003.101.12.1084
Encounter, Performed: Nursing Facility Visit	2.16.840.1.113883.3.464.1003.101.12.1012
Encounter, Performed: Observation	2.16.840.1.113883.3.464.1003.101.12.1086
Encounter, Performed: Outpatient	2.16.840.1.113883.3.464.1003.101.12.1087
Encounter, Performed: Palliative Care Encounter	2.16.840.1.113883.3.464.1003.101.12.1090
Intervention, Order: Hospice care ambulatory	2.16.840.1.113762.1.4.1108.15
Intervention, Performed: Hospice care ambulatory	2.16.840.1.113762.1.4.1108.15)
Intervention, Performed: Palliative Care Intervention	2.16.840.1.113883.3.464.1003.198.12.1135
Medication, Active: Dementia Medications	2.16.840.1.113883.3.464.1003.196.12.1510
Procedure, Performed: Total Colectomy	2.16.840.1.113883.3.464.1003.198.12.1019
Symptom: Frailty Symptom	2.16.840.1.113883.3.464.1003.113.12.1075

Numerator

Name	Value Set
Diagnostic Study, Performed: CT Colonography	2.16.840.1.113883.3.464.1003.108.12.1038
Laboratory Test, Performed: Fecal Occult Blood Test (FOBT)	2.16.840.1.113883.3.464.1003.198.12.1011
Laboratory Test, Performed: FIT DNA	2.16.840.1.113883.3.464.1003.108.12.1039
Procedure, Performed: Colonoscopy	2.16.840.1.113883.3.464.1003.108.12.1020
Procedure, Performed: Flexible Sigmoidoscopy	2.16.840.1.113883.3.464.1003.198.12.1010

Source(s)

eCQI CMS130