Colorectal Cancer Screening | eCQI Resource Center

Measure Information	2021 Performance Period
CMS Measure ID	CMS130v9
NQF Number	Not Applicable
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
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.
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 Exceptions	None
Measure Steward	National Committee for Quality Assurance
Quality Domain	Effective Clinical Care
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.
MIPS Quality ID	113
Meaningful Measure	Preventive Care
Telehealth Eligible	Yes
Next Version	CMS130v10
Previous Version	No Version Available

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Measure Information	2021 Performance Period	2022 Performance Period	2023 Performance Period
Name	Colorectal Cancer Screening	Colorectal Cancer Screening	Colorectal Cancer Screening
CMS Measure ID	CMS130v9	CMS130v10	CMS130v11
NQF Number	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
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
Denominator	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 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
Numerator Exclusions	Not Applicable	Not Applicable	Not Applicable
Denominator Exceptions	None	None	None
Measure Steward	National Committee for Quality Assurance	National Committee for Quality Assurance	National Committee for Quality Assurance
Quality Domain	Effective Clinical Care	Effective Clinical Care	Effective Clinical Care
Measure Scoring	Proportion measure	Proportion measure	Proportion measure
Measure Type	Process measure	Process measure	Process measure
Improvement Notation	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 (https://ecqi.healthit.gov/qdm) 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.
MIPS Quality ID	113	113	113
Meaningful Measure	Preventive Care	Preventive Care	Preventive Care
Telehealth Eligible	Yes	Yes	Yes
Next Version	CMS130v10	CMS130v11	No Version Available
Previous Version	No Version Available	CMS130v9	CMS130v10

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Data Element Repository

Data Elements contained within CMS130v9

Value Sets

Value Sets to be used with CMS130v9

Release Notes

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