WCHQ 20 Preventative Care: Colorectal Cancer Screening

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?

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.

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

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

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

HCPCS Code

Description

a outpatient

b evaluation and management

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

Effective 10/01/2015

0DTE4ZZ

Resection of Large Intestine, Percutaneous Endoscopic Approach

0DTE0ZZ

Resection of Large Intestine, Open Approach

0DTE7ZZ

0DTE8ZZ

Effective 10/01/2015

**Z90.49

Acquired absence of other specified parts of digestive tract

Table CCS-3: Codes to Identify Colorectal Cancer Screening

Effective 10/01/2015

0DJD8ZZ

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

Effective 10/01/2015