WCHQ Ambulatory Measure Specification

WCHQ 20 – Preventative Care: Colorectal Cancer Screening

Measurement Period 01/01/2016-12/31/2016

Process Measure Type

NQS Domain: Clinical Process/Effectiveness

Measure Description

The percentage of adults age 50 through 75 who had a minimum of one colorectal cancer screeningtest during the one year measurement period. (Refer to Table CCS-3 for qualifying tests and timeframes)

Disclaimer: Measures reported by WCHQ healthcare organizations represent a specific aspect of care in relation to an evidence-based standard, but are not clinical guidelines and do not establish standards of care.All providers should have an individual care plan established with their patient.

General Information/Rationale

The United States Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen men and women, at age 50 and older for colorectal cancer. The optimal interval for screening depends on the test. Annual fecal occult blood testing offers greater reductions in mortality rates than biennial screening. A 10-year interval has been recommended for colonoscopy, but a 5-year interval is recommended for flexible sigmoidoscopies because of their lower sensitivity. The USPSTF concluded that the benefits from screening for colorectal cancer substantially outweigh potential harms, and that regardless of screening strategy chosen, it is likely to be cost-effective1.

In persons identified as being at high-risk by their health care providers, initiating screening at an earlier age and at more frequent intervals is reasonable. It is recommended that all adults speak with their health care providers to determine, on an individual basis, the age at which to begin and end screenings, the best type of screening for individual circumstances, and the frequency of these screenings.

Reference The Guide to Clinical Preventive Service 2007-Recommendations and rationale: Screening For Colorectal Cancer U.S. Preventive Services Task Force (USPSTF). Retrieved December 17, 2007 from

Definitions

12 Months: Measurement Period

24 Months: Measurement Period plus Prior Year

36 Months: Measurement Period plus Prior Two Years

Primary Care Office Visit: Office visit in an outpatient, non-urgent care setting

PCP: For WCHQ measure purposes, a primary care provider is defined as any General Practice, Internal Medicine, Family Practice, Pediatrics provider with the following degree types (MD, DO, PA, NP), and any other practitioners identified by the healthcare system as primary care practitioners. The rationale for the additional practitioner(s) must be documented and must be applied consistently across all measures by the organization.

Age Range 50-75: Patients born between 01/01/1942and 01/01/1966

Denominator Description

Adults, whose age at the beginning of the one year measurement period is at least 50 and whose age at the end of the one year measurement period is less than 76 and who are alive as of the last day of the Measurement Period. Expired patients for whom a specific date of expiration cannot be found are excluded from the denominator population.

The rationale for the denominator population is built from the following criteria:

[Question 1] – Is this a patient whose care is managed within the physician group?

[Question 2] – Is this a patient currently managed in our system?

[Question 3] – Is this a patient that is eligible for colorectal cancer screening?

ENCOUNTER DATA

Patients eligible for inclusion in the denominator include:

[Question 1] –Is this a patient whose care is managed within the physician group?

Patients who had at least two Primary Care office visits (Table CCS-1), regardless of diagnosis code, on different dates of service, to a PCP in the past 36 months (Measurement Period plus Prior Two Years).

[Question 2] –Is this a patient currently managed in our system?

Patients who had at least one Primary Care office visit (Table CCS-1) regardless of diagnosis code, with a PCP in the most recent 24 months (Measurement Period plus Prior Year)

[Question 3] – Is this a patient that is eligible for Colorectal Cancer Screening?

  • Exclude those who have had a total colectomy (Table CCS-2). The organizations may look for exclusions as far back as possible in the patient’s history, through administrative data and/or medical record review. The exclusion can be identified through an ICD-9 diagnosis-based problem list. The problem must be ACTIVE. There is no limit on the look back date, but the date of documentation or onset date must occur prior to the end of the measurement period.

NUMERATOR DESCRIPTION

The number of eligible adults who had one or more screenings for colorectal cancer as defined by the following criteria:

  • Fecal Occult Blood Test (FOBT): During the measurement period (12 months)
  • One FOBT meets requirement. It does not need to be a three-panel test as it may not be possible to determine how many samples were tested.
  • Flexible Sigmoidoscopy: During the measurement period or the four years prior to the measurement period.
  • CT Colonography (virtual colonoscopy): 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.

This may be demonstrated through any of the following:

  • Administrative data, which can include:
  • Table CCS-3
  • Internal, external and/or patient reported screenings extracted electronically from an Electronic Medical Record (EMR), requiring one of the following:

Year test was performed

Date range test was performed, providing the entire range is within the measurement period.

NOTE: This does not include results with a date of documentation only; the actual year or date range of the test must be present and be within the numerator description timeframes for inclusion in the numerator.

  • Medical Record Review (Refer to Medical Record Review for Numerator Inclusion/Denominator Exclusion section

Internally Developed Codes – Data Translation/Mapping Requirements

If a medical group utilizes internally generated codes to identify specific services or events required for a given WCHQ performance measure, the group may translate or map the information to the WCHQ performance measurement specifications. The medical group must assure that the internally generated code matches the clinical specificity of the standard (ICD-9, CPT) codes included in the WCHQ performance measurement specifications.

In order to use internally developed codes for WCHQ performance measure reporting, the medical group needs to document the translation/mapping to the codes in the specifications. This documentation should include the internally generated code, a description of the internally developed code, any additional clinical information for the internally developed code, and the equivalent standard code with description from the WCHQ performance measurement specifications. Once the translation/ mapping documentation is established, the medical group’s WCHQ performance measurement team must review the mapping on a yearly basis and document that internally developed codes have not changed and are being used in the manner described in the translation/ mapping document.

The medical group must have documented processes in place for adding codes to the medical group’s administrative data system and procedures to implement the internally developed codes.

Medical Record Review for Numerator Inclusion/Denominator Exclusion

If appropriate, and/or when necessary, every organization may complement their electronic capture of patient medical history with electronic or manual record review. The following criteria apply only to data captured/reviewed during medical record review.

Numerator Inclusion

For WCHQ Preventive Screening Measures, which can include, internal, external, and/or patient reported test results, proof of numerator compliance requires one of the following:

Year test was performed

Date range test was performed, providing the entire range is within the measurement period.

NOTES:

This does not include results with a date of documentation only; the actual year or date range of the test must be present and be within the numerator description timeframes for inclusion in the numerator.

Screenings defined as a single specimen, such as that collected from a digital rectal examination, are not numerator compliant, for example:

  • CPT Code 82272 - Blood, occult, by perioxidase activity (eg guaiac), qualitative, feces, single specimen (eg, from digital rectal exam)

Denominator Exclusion

For all WCHQ Measures, proof of Denominator exclusion requires:

Existence of exclusion criteria.

These data may be retrieved, in whole or in part, from any of the following:

  • Notation in Progress Note
  • Notation in Medical History or Surgical History
  • Flag/Field in Electronic Medical Record
  • Documentation in patient chart

REQUIRED DATA SUBMISSION FIELDS

Fields required for data submission for this measure depend upon the methodology used. The fields are as follows:

Organization Level Reporting:

TOTAL POPULATION METHODOLOGY:

  • Population Denominator(N)(Patients Eligible for Colorectal Cancer Screening)
  • Numerator (Patients who had a minimum of one Colorectal Cancer Screen)

Upon entry of these numbers, the rate is automatically calculated

FIELDS REQUIRED FOR MEASURE VALIDATION

Validation of this measure will require patient level data samples for Administrative Data and patient level data collection tool samples for Manual Review. The following indicates fields needed for validation, which may be helpful to consider when querying the measure:

Denominator Data Sample fields:

  • Patient Identifier (can be medical record number or other ID)
  • Primary Care Office Visit Dates
  • Provider Specialty
  • Patient Date of Birth
  • Exclusion codes used for Colectomy
  • Date of Colectomy documentation

Numerator Data Sample fields:

Numerator data sample is from denominator data sample

  • Patient Identifier (can be medical record number or other ID)
  • Colorectal Cancer Screening Code or Description
  • Colorectal Cancer Screening Test Date

Appendix A

Primary Payer

In keeping with the changing atmosphere of quality measurement and reporting, WCHQ would like for participating organizations to include the primary payer source with their data submissions for the ambulatory care measures.

The primary payer source should be identified in the denominator upon answering the question, “Is this patient current in our system?” Once it has been determined that a patient is current because of a visit to their physician within the specified time period (12 months for chronic care measures and 24 months for preventive care measures), the payer should be “pulled” into the query. The primary payer should be the payer at the most recent office visit within the measurement period.

There will be four categories of primary payer that will need to be submitted to WCHQ via the data submission tool: Medicare FFS, Medicaid (all types), Commercial (including Medicare HMO) and Uninsured/Self-Pay. The raw numbers for the denominator and numerator should be included for all three types of data submission, total population, hybrid, and sample.

Rationale

Opportunities exist for WCHQ to collect and report data on specific populations, like the Medicare population, through grant applications to begin to understand the disparities in quality of care. The purpose of this is to begin to understand the challenges of putting in additional data elements and complexities of data display for public reporting. At this time, the primary payer information will not be publicly reported.

Definitions:

Commercial: All plans not Medicaid or Medicare FFS (IncludesVA, DoD, etc.)

FFS Medicare: FFS plans, not Medicare HMO (Medicare Railroad is FFS Medicare)

Medicaid: All Medicaid plans including those managed by commercial plans

Uninsured: Self-pay individuals

Appendix B

Code tables with descriptions. Reference also “WCHQ Measure Spec Code List.xls”

Table CCS-1: CPT Codes to Identify Outpatient Visits

CPT Codes / Description
99201-99205 / Office or OPa visit E&Mb, new patient
99212-99215 / Office or OP visit E&M, established patient
99241-99245 / Office or other OP consultations
99347-99350 / Home visit for evaluation and management of an established patient
99384-99387 / Initial preventive medicine E&Mb
99394-99397 / Periodic preventive medicine E&Mb
99401-99404 / Preventive medicine counseling
99411 / Preventive medicine counseling, group
99412 / Preventive medicine counseling, group
99420 / Risk assessment, admin and interpretation
99429 / Unlisted preventive medicine service
99488 / Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with one face-to-face visit, per calendar month.
99495 / Transitional Care Management Services (Moderate Complexity)
99496 / Transitional Care Management Services (High Complexity)
HCPCS Code
/

Description

G0344
(effective 01/01/2005) / Initial preventive physical examination; face-to-face visit services limited to new beneficiary during the first six months of Medicare enrollments
G0402
(Effective 01/01/09) / Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment
G0438 / Annual wellness visit; includes a personalized prevention plan of service, initial visit
G0439 / Annual wellness visit; includes a personalized prevention plan of service, subsequent visit

a outpatient

b evaluation and management

Table CCS-2: Codes to Identify Exclusions for Colorectal Cancer Screening

ICD-9-CM Procedure Codes / Description
45.8x / Total intra-abdominal colectomy
45.81 / Laparoscopic total intra-abdominal colectomy
45.82 / Open total intra-abdominal colectomy
45.83 / Other and unspecified total intra-abdominal colectomy

Effective 10/01/2015

ICD-10-PCSProcedure Codes / Description

0DTE4ZZ

/

Resection of Large Intestine, Percutaneous Endoscopic Approach

0DTE0ZZ

/

Resection of Large Intestine, Open Approach

0DTE7ZZ

/ Resection of Large Intestine, Via Natural or Artificial Opening

0DTE8ZZ

/ Resection of Large Intestine, Via Natural or Artificial Opening Endoscopic
ICD-9-CM Diagnosis Codes / Description
**V45.72 / Acquired absence of intestine (large, small)
**Code can be included at the organization’s discretion. If included, chart review is required for these visits.

Effective 10/01/2015

ICD-10-CM Diagnosis Codes / Description

**Z90.49

/

Acquired absence of other specified parts of digestive tract

**Code can be included at the organization’s discretion. If included, chart review is required for these visits.
CPT Codes / Description
44150 / Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy
44151 / Colectomy, total, abdominal, without proctectomy; with continent ileostomy
44152 (deleted 01/01/07) / Colectomy, total, abdominal, without proctectomy; with rectal mucosectomy, ileoanal anastomosis, with or without loop ileostomy
44153 (deleted 01/01/07) / Colectomy, total, abdominal, without proctectomy; 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 continent ileostomy
44157 / Colectomy, total abdominal, with proctectomy; with ileoanal anastomosis
44158 / Colectomy, total abdominal, with proctectomy; with ileoanal anastomosis and creation of ileal reservoir.
44210 / Colectomy, total, abdominal, without proctectomy, with ileostomy or ileoproctostomy
44211 / Colectomy, total, abdominal, with proctectomy, with ileoanal anastomosis, creationo of ileal reservoir (S or J), with loop ileostomy, includes rectal mucosectomy, when performed
44212 / Colectomy, total, abdominal, with proctectomy, with ileostomy
**44799 / Unlisted Procedure, Intestine
**Code can be included at the organization’s discretion. If included, chart review is required for these visits.
**45121 / Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with subtotal or total colectomy, with multiple biopsies
**Code can be included at the organization’s discretion. If included, chart review is required for these visits.

Table CCS-3: Codes to Identify Colorectal Cancer Screening

FECAL OCCULT BLOOD TEST (FOBT) CODES
(This test must have occurred during the Measurement Period – 12 months)
CPT Codes / Description
82270 / Blood, occult; feces screening, 1-3 simultaneous determinations
82274 / Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations
LOINC Codes / Description
2335-8 / Fecal Occult Blood
12503-9 / Fecal Occult Blood
12504-7 / Fecal Occult Blood
14563-1 / Fecal Occult Blood
14564-9 / Fecal Occult Blood
14565-6 / Fecal Occult Blood
27396-1 / Fecal Occult Blood
27401-9 / Fecal Occult Blood
27925-7 / Fecal Occult Blood
27926-5 / Fecal Occult Blood
29771-3 / Fecal Occult Blood
56490-6 / Fecal Occult Blood
56491-4 / Fecal Occult Blood
57905-2 / Fecal Occult Blood
HCPCS Codes / Description
G0328 / Colorectal cancer screening, fecal occult blood test, immunoassay, 1-3 simultaneous
FLEXIBLE SIGMOIDOSCOPY CODES
(This test must have occurred during the Measurement Period – 12 monthsor the four years prior to the Measurement Period)
CPT Codes / Description
45330 / Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure).
45331 / Sigmoidoscopy, flexible; with biopsy, single or multiple
45332 / Sigmoidoscopy, flexible; with removal of foreign body
45333 / Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
45334 / Sigmoidoscopy, flexible; with removal of foreign body
45335 / Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance
45337 / Sigmoidoscopy, flexible; with decompression of volvulus, any method
45338 / Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45339 / Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
45340 / Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures.
45341 / Sigmoidoscopy, flexible; with endoscopic ultrasound examination
45342 / Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s)
45345 / Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation)
ICD-9-CM Procedure Codes / Description
45.24 / Flexible sigmoidoscopy

Effective 10/01/2015

ICD-10-PCSProcedure Codes / Description

0DJD8ZZ

/

Inspection of Lower Intestinal Tract, Via Natural or Artificial Opening Endoscopic (Same as Colonoscopy code)

HCPCS Codes / Description
G0104 / Colorectal cancer screening; flexible sigmoidoscopy
CT COLONOGRAPY (Virtual Colonoscopy) CODES
(This test must have occurred during the Measurement Period – 12 monthsor the four years prior to the Measurement Period)
Category III CPT Codes / Description
0066T
Deleted 01/01/10 (leave in until 2014) / Computed tomographic (CT) colonography (ie. Virtual colonoscopy); screening
0067T
Deleted 01/01/10 (leave in until 2014) / Computed tomographic (CT) colonography (ie. Virtual colonoscopy); diagnostic
74261 / Diagnostic computerized tomographic colonography (CTC) without IV contrast
74262 / Diagnostic computerized tomographic colonography (CTC) with IV contrast
74263 / Screening computerized tomographic colonography (CTC)
COLONOSCOPY CODES
(This test must have occurred during the Measurement Period – 12 monthsor the nine years prior to the Measurement Period)
CPT Codes / Description
44388 / Colonoscopy through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
44389 / Colonoscopy through stoma; with biopsy, single or multiple
44390 / Colonoscopy through stoma; with removal of foreign body.
44391 / Colonoscopy through stoma; with control of bleeding, any method
44392 / Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
44393 / Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
44394 / Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
44397 / Colonoscopy through stoma; with transendoscopic stent placement (includes predilation)
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 (separate procedure)
45379 / Colonoscopy, flexible, proximal to splenic flexure; with removal of foreign body
45380 / Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple
45381 / Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance
45382 / Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (eg. Injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
45383 / Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare techique
45384 / Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
45385 / Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45386 / Colonoscopy, flexible, proximal to splenic flexure; with dilation by balloon, 1 or more strictures
45387 / Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation)
45391 / Colonoscopy, flexible, proximal to splenic flexure; with endoscopic ultrasound examination
45392 / Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s)
ICD-9-CM Procedure Codes / Description
45.22 / Endoscopy of large intestine through artificial stoma
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

Effective 10/01/2015