CMS 130 - Colorectal Cancer Screening

Overview

CMS130v8 (2020)
CMS130v9 (2021)
CMS130v10 (2022)

Identifiers

CMS eCQM IDNQF eCQM IDNQFMIPS Quality ID
CMS130v100034113
*MIE only supports data collection and reporting using eCQM specifications

Definitions

DescriptionPercentage of adults 50-75 years of age who had appropriate screening for colorectal cancer
Initial Patient PopulationPatients 50-75 years of age with a visit during the measurement period
DenominatorEquals Initial Population
Denominator Exclusions
  • 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

    • Advanced illness with one inpatient encounter during the measurement period or the year prior

    • Taking dementia medications during the measurement period or the year prior

  • Exclude patients receiving palliative care during the measurement period.

NumeratorPatients 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
Denominator Exceptions

Additional Information

Measure TypeProcess measure
Measure ScoringProportion measure
GranularityPatient
Improvement NotationHigher score indicates better quality
DomainEffective Clinical Care

Clinical Instructions

New UI Visit Encounter (valid RC202109+)

Original Visit Encounter

Ensure patients aged 50-75 are screened for colorectal cancer. Use the Past Procedures section of the encounter to record a previous Fecal Occult Blood Test (FOBT), Flexible Sigmoidoscopy, Colonoscopy Screening, FIT-DNA, or CT Colonography; otherwise, use the Visit Orders section of the encounter to order/perform one of the recognized procedures at the time of the encounter.

  1. While documenting the Visit encounter, either record the previous procedure or the receipt of the colorectal screening, or order and perform the screening, as appropriate:

    1. Option 1: Document in the Past Procedures section

      1. Open the Past Procedures section.
      2. Using the Procedure autocomplete, begin typing the name of the diagnostic procedure (e.g., Colonoscopy) with the appropriate Concept ID.
      3. Add the Date and any relevant Notes.
      4. Click the Next button, or close the section.
    2. Option 2: Document in the Preventive Care section 

      1. Open the Preventive Care section.
      2. Provide the date of the last reported procedure in the Enter New Date field (e.g., 01-17-2019). This date is the Last Reported Date.
      3. Click the Next button, or close the section.
    3. Option 3: Document in the Tests and Procedures section IF performing the screening in-house

      1. Open the Tests and Procedures section.
      2. Using the autocomplete, begin typing the appropriate procedure name.
      3. Click the Add to Exam button.
      4. After adding the new section, open the procedure section and add any results or findings.
      5. Click the Next button, or close the section.
  2. Continue documenting the encounter, as needed.

  3. When completed, Close and Archive the encounter.

  • Option 4: Scan/Index or Upload an accepted screening document

    • Using WebScan , scan and index the appropriate document type configured with the necessary LOIN-C.

      • Scan/Index or Upload the Colonoscopy Screening document type (COLON) configured with the necessary Concept ID (73761001).
      • Scan/Index or Upload the Fecal Occult Blood Test document type (FOBT) configured with the necessary LOIN-C (2335-8); otherwise, add the FOBT observation and ensure it is configured with the 2335-8 LOIN-C.
      • Scan/Index or Upload the Flexible Sigmoidoscopy document type (FLEXSIG) configured with the necessary Concept ID (44441009).
      • Scan/Index or Upload the Computed Tomographic Colongraphy document type (CTC) configured with the necessary Concept ID (418714002).
      • Add the Fit DNA observation to the chart either manually, or via an established interface, and ensure the observation is configured with the 77354-9 LOIN-C.

Evidence

Initial Patient Population

NameValue Set
Encounter, Performed: Annual Wellness Visit2.16.840.1.113883.3.526.3.1240
Encounter, Performed: Home Healthcare Services2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed: Office Visit2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed: Online Assessments2.16.840.1.113883.3.464.1003.101.12.1089
Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up2.16.840.1.113883.3.464.1003.101.12.1025
Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up2.16.840.1.113883.3.464.1003.101.12.1023
Encounter, Performed: Telephone Visits2.16.840.1.113883.3.464.1003.101.12.1080

Denominator Exclusions

NameValue Set
Assessment, Performed: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)LOINC Code 71007-9
Device, Applied: Frailty Device2.16.840.1.113883.3.464.1003.118.12.1300
Device, Order: Frailty Device2.16.840.1.113883.3.464.1003.118.12.1300
Diagnosis: Frailty Diagnosis2.16.840.1.113883.3.464.1003.113.12.1074
Diagnosis: Malignant Neoplasm of Colon2.16.840.1.113883.3.464.1003.108.12.1001
Encounter, Performed: Acute Inpatient2.16.840.1.113883.3.464.1003.101.12.1083
Encounter, Performed: Care Services in Long-Term Residential Facility2.16.840.1.113883.3.464.1003.101.12.1014
Encounter, Performed: Emergency Department Visit2.16.840.1.113883.3.464.1003.101.12.1010
Encounter, Performed: Encounter Inpatient2.16.840.1.113883.3.666.5.307
Encounter, Performed: Frailty Encounter2.16.840.1.113883.3.464.1003.101.12.1088
Encounter, Performed: Nonacute Inpatient2.16.840.1.113883.3.464.1003.101.12.1084
Encounter, Performed: Nursing Facility Visit2.16.840.1.113883.3.464.1003.101.12.1012
Encounter, Performed: Observation2.16.840.1.113883.3.464.1003.101.12.1086
Encounter, Performed: Outpatient2.16.840.1.113883.3.464.1003.101.12.1087
Encounter, Performed: Palliative Care Encounter2.16.840.1.113883.3.464.1003.101.12.1090
Intervention, Order: Hospice care ambulatory2.16.840.1.113762.1.4.1108.15
Intervention, Performed: Hospice care ambulatory2.16.840.1.113762.1.4.1108.15)
Intervention, Performed: Palliative Care Intervention2.16.840.1.113883.3.464.1003.198.12.1135
Medication, Active: Dementia Medications2.16.840.1.113883.3.464.1003.196.12.1510
Procedure, Performed: Total Colectomy2.16.840.1.113883.3.464.1003.198.12.1019
Symptom: Frailty Symptom2.16.840.1.113883.3.464.1003.113.12.1075

Numerator

NameValue Set
Diagnostic Study, Performed: CT Colonography2.16.840.1.113883.3.464.1003.108.12.1038
Laboratory Test, Performed: Fecal Occult Blood Test (FOBT)2.16.840.1.113883.3.464.1003.198.12.1011
Laboratory Test, Performed: FIT DNA2.16.840.1.113883.3.464.1003.108.12.1039
Procedure, Performed: Colonoscopy2.16.840.1.113883.3.464.1003.108.12.1020
Procedure, Performed: Flexible Sigmoidoscopy2.16.840.1.113883.3.464.1003.198.12.1010

Source(s)

eCQI CMS130


Enterprise Health Documentation

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