Measure Name: Colorectal Screen Owner: NCQA (COL) Measure Code: COL Lab Data: N Rule Description: The percentage of members 50-75 years of age who had appropriate for . General Criteria Summary 1. Continuous enrollment: 2 year 2. Anchor date: 31st December of the measurement year 3. Gaps in enrollment: One 45-day gap allowed in each year of continuous enrollment 4. Medical coverage: Yes 5. Drug coverage: No 6. Attribution time frame:2 year 7. Exclusions apply: Yes, when numerator is negative 8. Age range: 50-75 years

Summary of changes for 2013 No changes ------Denominator Description: All members aged 51-75 years at the end of the measurement year Inclusion Criteria: Members who meet the age requirement in the measurement year and continuous enrollment criteria as summarized above for the coverage required. There are no claims criteria for the denominator population. Eligibility Criteria Condition # Detailed Criteria Timeframe Description Evnt Age is 51-75 Age in Years = 51-75 As of the end of the measurement year

AND Has medical coverage Coverage Indicator Medical = Y During measurement year and the year prior to the measurement year

3/7/2014 Page 1 Exclusion Criteria: Members with a diagnosis of colorectal cancer or total

Condition # Detailed Criteria Timeframe Description Evnt Diagnosis of colorectal 1 Any Diagnosis Code for Colorectal Cancer Anytime prior to or during the measurement year cancer Table COL-B: Codes to Identify Exclusions Or HCPCS Procedure Code for Colorectal Cancer Table COL-B: Codes to Identify Exclusions OR Total colectomy 1 CPT Procedure Code for Total Colectomy Anytime prior to or during the measurement year procedure done Table COL-B: Codes to Identify Exclusions Or ICD9 Procedure Code for Total Colectomy Table COL-B: Codes to Identify Exclusions

Exclusion Note: The exclusions are applied according to the general NCQA rule of considering exclusions only if the numerator is negative ------

Numerator Description: For each member who meets the denominator criteria, those who received appropriate screening for colorectal cancer

Inclusion Criteria: Members who had at least one of three possible procedures used for colorectal , within the timeframe specified for the indicated procedure

Condition # Detailed Criteria Timeframe Description Evnt Fecal occult test 1 CPT Procedure Codes for FOBT During the measurement year (FOBT) done Table COL-A: Codes to Identify Colorectal Cancer Screening Or HCPCS Procedure Codes for FOBT Table COL-A: Codes to Identify Colorectal Cancer Screening OR Flexible 1 CPT Procedure Codes for Flexible During the measurement year or up to four years prior to the measurement year done sigmoidoscopy Table COL-A: Codes to Identify Colorectal Cancer Screening Or HCPCS Procedure Codes for Flexible

3/7/2014 Page 2 sigmoidoscopy Table COL-A: Codes to Identify Colorectal Cancer Screening Or ICD9 Procedure Codes for Flexible sigmoidoscopy Table COL-A: Codes to Identify Colorectal Cancer Screening OR done 1 CPT Procedure Code for Colonoscopy During the measurement year or up to nine years prior to the measurement year Table COL-A: Codes to Identify Colorectal Cancer Screening Or HCPCS Procedure Code for Colonoscopy Table COL-A: Codes to Identify Colorectal Cancer Screening Or ICD9 Procedure Code for Colonoscopy) Table COL-A: Codes to Identify Colorectal Cancer Screening

Notes: 1. The timeframe required for colon cancer screening varies depending on the type of test or procedure done. FOBTs are generally done annually, while sigmoidoscopies are generally done every 5 years, and are generally done every 5-10 years. Because HCSC has historical data, the search for both the qualifying tests and exclusion criteria extend to 10 years of data. 2. In 2012, ICD-9 Diagnosis code V76.51 was deleted from Table COL-A. 3. In 2012, HCPCS code G0394 was deleted from Table COL-A.

3/7/2014 Page 3 Appendix

Table COL-A: Codes to Identify Colorectal Cancer Screening CPT Procedure Code Description: FOBT 82270 Blood, occult, , by peroxidase activity (guaiac) 82274 Blood, occult, feces, by fecal determination by immunoassay

HCPCS Description: FOBT G0328 Colorectal cancer screening, fecal-occult blood test, immunoassay, 1-3 simultaneous determinations

LOINC Description: FOBT 2335-8 test 12503-9 Fecal occult blood test 12504-7 Fecal occult blood test 14563-1 Fecal occult blood test 14564-9 Fecal occult blood test 14565-6 Fecal occult blood test 27396-1 Fecal occult blood test 27401-9 Fecal occult blood test 27925-7 Fecal occult blood test 27926-5 Fecal occult blood test 29771-3 Fecal occult blood test 56490-6 Fecal occult blood test 56491-4 Fecal occult blood test 57905-2 Fecal occult blood test 58453-2 Fecal occult blood test

CPT Procedure Code Description: Flexible Sigmoidoscopy 45330 Sigmoidoscopy, flexible, diagnostic, with or without collection of specimen

45331 Sigmoidoscopy, with biopsy, single or multiple 45332 Sigmoidoscopy, with removal of foreign body 45333 Sigmoidoscopy, with removal of tumors, polyps, by hot biopsy forceps or bipolar cautery

45334 Sigmoidoscopy, with control of bleeding 45335 Sigmoidoscopy, with directed submucosal injections, any substance

3/7/2014 Page 4 45337 Sigmoidoscopy, with decompression of volvulus, any method 45338 Sigmoidoscopy, with removal of tumor, , or lesions by snare technique

45339 Sigmoidoscopy, with ablation of tumor, polyp, or other lesions not amenable to removal by hot biopsy forceps bipolar cautery or snare technique

45340 Sigmoidoscopy, with dilation by balloon, 1or more strictures 45341 Sigmoidoscopy, with endoscopic ultrasound examination 45342 Sigmoidoscopy, with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy

45345 Sigmoidoscopy, with transendoscopic stent placement HCPCS Description: Flexible Sigmoidoscopy G0104 Colorectal cancer screening, flexible ICD-9-CM Procedure Description: Flexible Sigmoidoscopy 45.24 Flexible sigmoidoscopy

CPT Procedure Code Description: Colonoscopy 44388 Colonoscopy through stroma, diagnostic, with or without collection of specimens

44389 Colonoscopy, with biopsy single or multiple 44390 Colonoscopy, with removal of foreign body 44391 Colonoscopy with control of bleeding 44392 Colonoscopy with removal of tumors, polyps, or other lesions by hot biopsy forceps or bipolar cautery

44393 Colonoscopy with ablation of tumors, polyps, or other lesions not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

44394 Colonoscopy, with removal of tumors, polyps, or other lesions by snare technique

44397 Colonoscopy with transendoscopic stent placement 45355 Colonoscopy, rigid or flexible, transabdominal via colotomy, single or multiple 45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression 45379 with removal of foreign body 45380 with biopsy, single or multiple 45381 Colonoscopy, flexible, proximal to the splenic flexure; with directed submucosal injection(s), any substance 45382 with control of bleeding, any method

3/7/2014 Page 5 45383 amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 45384 with removal of tumor(s), polyp(s) or other lesion(s) by hot biopsy forceps or bipolar cautery 45385 with removal of tumor(s), polyp(s) or other lesion(s) by snare technique 45386 with dilation by balloon, 1 or more strictures 45387 with transendoscopic stent placement 45391 Colonoscopy, flexible, proximal to splenic flexure; with endoscopic ultrasound examination 45392 with transendoscopic ultrasound- guided intramural or transmural fine needle aspiration/biopsy(s) HCPCS Description: Colonoscopy G0105 Colorectal cancer screening, colonoscopy on individual at high risk G0121 Colorectal cancer screening, colonoscopy on individual not meeting criteria for high risk ICD-9-CM Procedure Description: Colonoscopy 45.22 of through artificial 45.23 Colonoscopy 45.25 Closed endoscopic biopsy of large intestine

45.42 Endoscopic polypectomy of large intestine

45.43 Endoscopic destruction of other lesion or tissue of large intestine

Table COL-B: Codes to Identify Exclusions ICD-9-CM Diagnosis Description: Colorectal Cancer 153 Malignant neoplasm of colon 154.0 Malignant neoplasm of rectosigmoid junction 154.1 Malignant neoplasm of 197.5 Secondary malignant neoplasm, large intestine and rectum V10.05 Personal history of malignant neoplasm, large intestine HCPCS Description: Colorectal Cancer G0213 Colorectal cancer G0214 Colorectal cancer G0215 Colorectal cancer G0231 Colorectal cancer

CPT Procedure Code Description: Total Colectomy

3/7/2014 Page 6 44150 Colectomy, total, abdominal, without proctectomy with or ileoproctostomy

44151 Colectomy, with continent ileostomy 44152 Colectomy, with rectal mucosectomy, ileoanal , with or without loop ileostomy

44153 Colectomy, with rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir (S or J) with or without loop ileostomy

44155 Colectomy, total, abdominal, with proctectomy with ileostomy

44156 Colectomy, total, abdominal, with proctectomy with ileostomy, with continent ileostomy

44157 Colectomy, total, abdominal, with proctectomy with ileostomy, with ileoanal anastomosis, includes loop ileostomy, and rectal mucosectomy, when performed

44158 Colectomy, total, abdominal, with proctectomy with ileostomy, with ileoanal anastomosis, creation of ileal reservoir (S or J) includes loop ileostomy, and rectal mucosectomy, when performed

44210 Colectomy, total, abdominal, without proctectomy, with ileostomy or ileoproctostomy

44211 Colectomy, total, abdominal, with proctectomy, with ileoanal anastomosis, creation of ileal reservoir (S or J) includes loop ileostomy, and rectal mucosectomy, when performed

44212 Colectomy, total, abdominal, with proctectomy, with ileostomy

ICD-9-CM Procedure Description: Total Colectomy 45.8 Total intra abdominal colectomy

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