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CMS 130 - Colorectal Cancer Screening

Updated: 06/13/2023|Views: 2191

CMS 130 / Quality ID #113

Percentage of adults 45-75 years of age who had appropriate screening for colorectal cancer.

Denominator: Patients 46-75 years of age by the end of the measurement period, with a visit during the measurement period.
  • Patient’s age is calculated based on the patient’s Date of Birth, which was entered when you created the patient’s account.
  • Create a note detailing the patient’s office visit.
Denominator Exclusions: Exclude patients who are in hospice care for any part of the measurement period.
  • Hospice is documented under Hospice in History. These patients will be excluded from the denominator.

Exclude patients with a diagnosis or past history of total colectomy or colorectal cancer.

  • "Total Colectomy" is documented in Hospitalizations/Procedures. These patients will be excluded from the denominator.
  • Colorectal cancer is documented under Problems with a Start Date.

Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period.

  • Long Term Care is documented under Long Term Care Facility in History. These patients will be excluded from the denominator.
  • Patient’s age is calculated based on the patient’s Date of Birth.

Exclude patients 66 and older by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advance illness criteria:

  1. Advanced illness with two outpatient encounters during the measurement period or the year prior, OR
  2. Advanced illness with one inpatient encounter during the measurement period or the year prior, OR
  3. Taking dementia medications during the measurement period or the year prior
  • Patient’s age is calculated based on the patient’s Date of Birth.
  • "Advanced Illness" and "Frailty" is documented under Problems with a Start Date.
  • “Dementia Medications” are documented under Medications.

Exclude patients receiving palliative care for any part of the measurement period.

  • "Palliative Care" is documented under Problems with a Start Date.
Numerator: Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:
  1. Fecal occult blood test (FOBT) during the measurement period
  2. FIT-DNA (Cologuard) during the measurement period or the two years prior to the measurement period
  3. Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period
  4. CT Colonography during the measurement period or the four years prior to the measurement period
  5. Colonoscopy during the measurement period or the nine years prior to the measurement period
  • "Fecal Occult Blood Test (FOBT)" is ordered in Labs/Studies during the measurement period.
  • "Flexible Sigmoidoscopy" is documented under Hospitalizations/Procedures with a date that is during the measurement period or the four years prior to the measurement period. Or, it can also be documented in the Problem List with a Start Date.
  • "Colonoscopy" is documented under Hospitalizations/Procedures with a date that is during the measurement period or within the nine years prior to the measurement period.
  • A "FIT-DNA" test order is created in Labs/Studies AND the order is submitted via eLabs.
  • A "CT Colonography" is documented under Hospitalizations/Procedures with a date that is during the measurement period or within the nine years prior to the measurement period.
Office Visit Documentation:

Once all steps have been completed, the measure will be added to the Quality Measures Report.

Measure type: Process
High Priority Measure: No
Telehealth Eligible: Yes
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