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Colorectal Cancer Screening

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Measure Information 2021 Performance Period
CMS eCQM ID CMS130v9
NQF Number Not Applicable
MIPS Quality ID 113
Description

Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer
Initial Population

Patients 50-75 years of age with a visit during the measurement period
Numerator

Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:

- Fecal occult blood test (FOBT) during the measurement period

- Flexible sigmoidoscopy 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

- FIT-DNA during the measurement period or the two years prior to the measurement period

- CT Colonography during the measurement period or the four years prior to the measurement period
Numerator Exclusions

Not Applicable
Denominator

Equals Initial Population
Denominator Exclusions

Exclude patients whose hospice care overlaps the measurement period.

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

Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period.

Exclude patients 66 and older with advanced illness and frailty because it is unlikely that patients will benefit from the services being measured.
Denominator Exceptions

None
Steward National Committee for Quality Assurance
Measure Scoring Proportion measure
Measure Type Process measure
Improvement Notation

Higher score indicates better quality
Guidance

Patient self-report for procedures as well as diagnostic studies should be recorded in "Procedure, Performed" template or "Diagnostic Study, Performed" template in QRDA-1.

Do not count digital rectal exams (DRE), fecal occult blood tests (FOBTs) performed in an office setting or performed on a sample collected via DRE.

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.
Telehealth Eligible Yes
Next Version
CMS130v10
Previous Version No Version Available

Compare eCQM Versions

The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.

Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.

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Measure Information 2021 Performance Period 2022 Performance Period 2023 Performance Period 2024 Performance Period
Title Colorectal Cancer Screening Colorectal Cancer Screening Colorectal Cancer Screening Colorectal Cancer Screening
CMS eCQM ID CMS130v9 CMS130v10 CMS130v11 CMS130v12
NQF Number Not Applicable Not Applicable Not Applicable Not Applicable
Description

Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer

Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer

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

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

Patients 50-75 years of age with a visit during the measurement period

Patients 50-75 years of age with a visit during the measurement period

Patients 46-75 years of age by the end of the measurement period with a visit during the measurement period

Patients 46-75 years of age by the end of the measurement period with a visit during the measurement period
Denominator

Equals Initial Population

Equals Initial Population

Equals Initial Population

Equals Initial Population
Denominator Exclusions Exclude patients whose hospice care overlaps the measurement period. Exclude patients with a diagnosis or past history of total colectomy or colorectal cancer. Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period. Exclude patients 66 and older with advanced illness and frailty because it is unlikely that patients will benefit from the services being measured. Exclude patients who are in hospice care for any part of the measurement period. Exclude patients with a diagnosis or past history of total colectomy or colorectal cancer. Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period. Exclude patients 66 and older with an indication of frailty for any part of the measurement period who meet any of the following criteria: - Advanced illness with two outpatient encounters during the measurement period or the year prior - OR advanced illness with one inpatient encounter during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior Exclude patients receiving palliative care during the measurement period. Exclude patients who are in hospice care for any part of the measurement period. Exclude patients with a diagnosis or past history of total colectomy or colorectal cancer. 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. 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 advanced illness criteria: - Advanced illness with two outpatient encounters during the measurement period or the year prior - OR advanced illness with one inpatient encounter during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior Exclude patients receiving palliative care for any part of the measurement period. Exclude patients who are in hospice care for any part of the measurement period.Exclude patients with a diagnosis or past history of total colectomy or colorectal cancer.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.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 advanced illness criteria:- Advanced illness with two outpatient encounters during the measurement period or the year prior- OR advanced illness with one inpatient encounter during the measurement period or the year prior- OR taking dementia medications during the measurement period or the year priorExclude patients receiving palliative care for any part of the measurement period.
Numerator

Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:

- Fecal occult blood test (FOBT) during the measurement period

- Flexible sigmoidoscopy 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

- FIT-DNA during the measurement period or the two years prior to the measurement period

- CT Colonography during the measurement period or the four years prior to the measurement period

Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:

- Fecal occult blood test (FOBT) during the measurement period

- Flexible sigmoidoscopy 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

- FIT-DNA during the measurement period or the two years prior to the measurement period

- CT Colonography during the measurement period or the four years prior to the measurement period

Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:

- Fecal occult blood test (FOBT) during the measurement period

- FIT-DNA during the measurement period or the two years prior to the measurement period

- Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period

- CT Colonography 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

Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:

- Fecal occult blood test (FOBT) during the measurement period

- Stool DNA (sDNA) with FIT test during the measurement period or the two years prior to the measurement period

- Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period

- CT Colonography 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
Numerator Exclusions

Not Applicable

Not Applicable

Not Applicable

Not Applicable
Denominator Exceptions

None

None

None

None
Measure Steward National Committee for Quality Assurance National Committee for Quality Assurance National Committee for Quality Assurance National Committee for Quality Assurance
Measure Scoring Proportion measure Proportion measure Proportion measure Proportion measure
Measure Type Process measure Process measure Process measure Process measure
Improvement Notation

Higher score indicates better quality

Higher score indicates better quality

Higher score indicates better quality

Higher score indicates better quality
Guidance

Patient self-report for procedures as well as diagnostic studies should be recorded in "Procedure, Performed" template or "Diagnostic Study, Performed" template in QRDA-1.

Do not count digital rectal exams (DRE), fecal occult blood tests (FOBTs) performed in an office setting or performed on a sample collected via DRE.

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

Patient self-report for procedures as well as diagnostic studies should be recorded in "Procedure, Performed" template or "Diagnostic Study, Performed" template in QRDA-1.

Do not count digital rectal exams (DRE), fecal occult blood tests (FOBTs) performed in an office setting or performed on a sample collected via DRE.

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

Do not count digital rectal exams (DRE), fecal occult blood tests (FOBTs) performed in an office setting or performed on a sample collected via DRE.

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

Do not count digital rectal exams (DRE), fecal occult blood tests (FOBTs) performed in an office setting or performed on a sample collected via DRE.

Please note the measure may include screenings performed outside the age range of patients referenced in the initial population. Screenings that occur prior to the measurement period are valid to meet measure criteria.

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.
MIPS Quality ID 113 113 113 113
Telehealth Eligible Yes Yes Yes Yes
Next Version CMS130v10 CMS130v11 CMS130v12 No Version Available
Previous Version No Version Available
CMS130v9
CMS130v10
CMS130v11
Notes
Download XML
Download CSV
Specifications
Attachment Size
CMS130v9.html 71.18 KB
CMS130v9.zip 92.44 KB
CMS130v9-TRN.xlsx 22.28 KB

Data Element Repository

Value Sets
Value Sets to be used with CMS130v9
CMS130v9-TRN.xlsx

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​Updated the rationale to remove outdated references and content and to update references.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Standards Update

  • Added text to identify the Quality Data Model (QDM) version used in the measure specification.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Added text to indicate whether the measure is patient-based or episode-based.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Updated guidance to spell out digital rectal exam (DRE) and fecal occult blood test (FOBT) to improve clarity.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Added 'Exclude' to denominator exclusions to improve clarity.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated denominator exclusions to add the word 'consecutive' to clarify that the Long-Term Illness (LTI) exclusion should be for 90 consecutive days.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

Logic

  • Updated denominator exclusion logic for frailty and clarified that the long-term illness exclusion should be for 90 'consecutive' days to reduce ambiguity.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000). Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • CQL Library version update: Updated version number of the Hospice Library (Hospice-2.2.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • CQL Library version update: Updated version number of the Adult_Outpatient_Encounters Library (Adult_Outpatient_Encounters-1.3.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated CQL Library version number of the advanced illness and frailty exclusion library (AdvancedIllnessandFrailtyExclusionECQM-5.5.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set Frailty Symptom (2.16.840.1.113883.3.464.1003.113.12.1075): Deleted 4 SNOMED CT codes (267031002, 272060000, 272062008, 314109004) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Nursing Facility Visit (2.16.840.1.113883.3.464.1003.101.12.1012): Added 3 CPT codes (99315, 99316, 99318) based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations, to capture additional nursing facility visit encounter types.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Acute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1083): Deleted 1 SNOMED CT code (2876009) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Frailty Device (2.16.840.1.113883.3.464.1003.118.12.1300): Removed extensional value set Frailty Device (2.16.840.1.113883.3.464.1003.118.11.1114) with HCPCS codes from the grouping and added Frailty Device SNOMED (2.16.840.1.113883.3.464.1003.118.11.1220) with SNOMED CT codes to the grouping to align with recommended terminology.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Colonoscopy (2.16.840.1.113883.3.464.1003.108.12.1020): Deleted 5 CPT codes (44393, 44397, 45355, 45383, 45387) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Malignant Neoplasm of Colon (2.16.840.1.113883.3.464.1003.108.12.1001): Deleted 1 SNOMED CT code (187758006) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Total Colectomy (2.16.840.1.113883.3.464.1003.198.12.1019): Deleted 2 CPT codes (44152, 44153) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: Apr 24, 2023