CMS130 / #113 — Colorectal cancer screening
Patients who had appropriate screening for colorectal cancer.
Denominator
Section titled “Denominator”- Age: 45–75 at the encounter for the MIPS CQM, 46–75 at the end of the period for the eCQM.
- A qualifying encounter in the measurement period.
Numerator: any one test within its window
Section titled “Numerator: any one test within its window”| Test | Window |
|---|---|
| Fecal occult blood test (FOBT) | Measurement period only |
| Stool DNA with FIT (sDNA-FIT) | Measurement period and the 2 years before |
| Flexible sigmoidoscopy | Measurement period and the 4 years before |
| CT colonography | Measurement period and the 4 years before |
| Colonoscopy | Measurement period and the 9 years before |
Colonoscopy reaches back ten years, so you need full patient history, not only the measurement
year — don’t apply a _since or date filter that cuts it off.
Where to look
Section titled “Where to look”Observation(lab tests: FOBT, sDNA-FIT);DiagnosticReportandProcedure(endoscopies, CT colonography);DocumentReferenceof procedure-note types;- CPT codes on
Encounter.type; - text fallbacks for poorly coded EHRs.
Historical procedures sometimes have a year-only date. Decide how a year-only date is compared with each window and apply it consistently.
Lab tests need a result
Section titled “Lab tests need a result”FOBT and sDNA-FIT count only if resulted. An ordered test with no value does not count.
In QRDA I, the result may be on the lab test entry or in a nested result observation. A value of
nullFlavor="UNK" alone means there is no result.
A generic “colorectal screening performed” registry code should count only when the record also states which test was done.
Exclusions
Section titled “Exclusions”- Colorectal cancer (malignant neoplasm of the colon).
- Total colectomy.
- Hospice, palliative care, age 66+ in long-term care, and age 66+ with frailty plus advanced illness or dementia medication.