Measure : Follow-Up After Initial Diagnosis and Treatment Of Colorectal Cancer: Colonoscopy Owner: NQF (#0572) Measure Code: CLF Lab Data: N Steward: Health Benchmarks-IMS Health Rule Description: Percentage of all eligible members who have been newly diagnosed and resected with colorectal cancer who receive a follow-up colonoscopy within 15 months of resection. Applicable Provider Specialty: Physician Group General Criteria Summary Oncology, Colorectal Surgery, Gastroenterology, Internal Medicine, Family Practice, General Surgery, Geriatric Medicine, Multispecialty 1. Measurement period: 1 year prior to measurement period end date 2. Continuous enrollment: 15 months after index date 3. Anchor date: First instance of partial colectomy or tectomy during the year ending 15 months prior to the end of the measurement year 4. Gaps in enrollment: One 45-day gap allowed in the 15 months after the index date 5. Medical coverage: Yes 6. Drug coverage: No 7. Attribution time frame: 1day through 15 months post index event for all E&M visits 8. Exclusions apply: Yes 9. Age range: 18 years or older as of the beginning of the measurement year Summary of changes for 2015 No changes ----------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------- Denominator Description: Continuously enrolled members who are status post resection of colorectal cancer during the year ending 15 months prior to the measurement year. Inclusion Criteria: Continuously enrolled members who are status post resection of colorectal cancer during the year ending 15 months prior to the measurement year. Eligibility Criteria Condition Description # Evnt Detailed Criteria Field Dimen Fact Timeframe Age is 18 years or older Age in Years >= 18 age_years demog eligibility As of the beginning of measurement year Page 1
Claim Criteria Condition Description # Evnt Detailed Criteria Field Dimen Fact Timeframe Diagnosis of colorectal cancer 1 Any Diagnosis Code = CLF-A: Codes to Identify Colorectal Cancer Diagnosis AND (diagnosis must be on same claim as edure code) Partial colectomy or tectomy 1 CPT Procedure Code = CLF-B: Codes to Identify Partial Colectomy or Proctectomy OR ICD9 Procedure Code = CLF-B: Codes to Identify Partial Colectomy or Proctectomy dx_cd dx any_dx _cd fac_dtl _cd any_fac fac_dtl From 27 months prior to the end of the measurement year through 15 months prior to the end of the measurement year From 27 months prior to the end of the measurement year through 15 months prior to the end of the measurement year (Select the first date as the index date) Continuous Enrollment Criteria: Condition Description # Evnt Detailed Criteria Field Dimen Fact Timeframe Continuous enrollment AND Has medical coverage Continuous Enrollment is 15 months after index date Coverage Indicator Medical = Y medical_c ovg_ind 0-15 months after index date plan eligibility 0-15 months after index date ----------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------- Page 2
Exclusion Criteria: Members who are status post resection of colon cancer any time prior to the index date, or members who were in hospice care 0 to 15 months after the index date. Condition Description # Evnt Detailed Criteria Field Dimen Fact Timeframe Post resection of colorectal cancer 1 Any Diagnosis = CLF-C: Codes to Identify Post Resection of Colorectal Cancer And (CPT Procedure = CLF-C: Codes to Identify Post Resection of Colorectal Cancer ICD9 Procedure Code = CLF-C: Codes to Identify Post Resection of Colorectal Cancer) OR Hospice care 1 Any Diagnosis Code = CLF-D: Codes to Identify Hospice Care CPT Procedure Code = CLF-D: Codes to Identify Hospice Care HCPCS codes = CLF-D: Codes to Identify Hospice Care UB Revenue codes = CLF-D: Codes to Identify Hospice Care UB type of bill codes = CLF-D: Codes to Identify Hospice Care dx_cd dx any_dx _cd fac_dtl _cd dx_cd any_fac dx any_dx fac_dtl _cd fac_dtl _cd fac_dtl fac_revenu e_cd fac_dtl Any time prior to the index date (Select the first edure date as the exclusion date) 0 to 15 months after the index date. Page 3
Place of service = CLF-D: Codes to Identify Hospice Care mdst_place _cd clm_gen eral Numerator Description: Members receiving a colonoscopy, sigmoidoscopy, or protoscopy as appropriate during the 15 months after the index date. Inclusion Criteria: Members receiving a colonoscopy, sigmoidoscopy, or protoscopy as appropriate during the 15 months after the index date. Condition Description # Evnt Detailed Criteria Field Dimen Fact Timeframe Colonoscopy, sigmoidoscopy, or protoscopy 1 CPT Procedure Code = CLF-E: Codes to Identify Colonoscopy, Sigmoidoscopy, or Protoscopy OR HCPCS codes = CLF-E: Codes to Identify Colonoscopy, Sigmoidoscopy, or Protoscopy OR ICD9 Procedure Code = CLF-E: Codes to Identify Colonoscopy, Sigmoidoscopy, or Protoscopy _cd fac_dtl _cd fac_dtl _cd any_fac fac_dtl 0-15 months after index date Notes: 1. CPT code 45170 was deleted in 2009, but is retained in the specification. 2. CPT code 99376 is deleted but retained in the specification. 3. HCPCS code G0065 is deleted but retained in the specification. Page 4
Appendix CLF-A: Codes to Identify Colorectal Cancer Diagnosis Code Code Type Description 1530 ICD-9-CM Diagnosis Mal Neo Hepatic Flexure 1531 ICD-9-CM Diagnosis Mal Neo Transverse Colon 1532 ICD-9-CM Diagnosis Mal Neo Descend Colon 1533 ICD-9-CM Diagnosis Mal Neo Sigmoid Colon 1534 ICD-9-CM Diagnosis Malignant Neoplasm Cecum 1536 ICD-9-CM Diagnosis Malig Neo Ascend Colon 1537 ICD-9-CM Diagnosis Mal Neo Splenic Flexure 1538 ICD-9-CM Diagnosis Malignant Neo Colon NEC 1539 ICD-9-CM Diagnosis Malignant Neo Colon NOS 1540 ICD-9-CM Diagnosis Mal Neo Rectosigmoid Jct 1541 ICD-9-CM Diagnosis Malignant Neopl Rectum 1548 ICD-9-CM Diagnosis Mal Neo Rectum/Anus NEC CLF-B: Codes to Identify Partial Colectomy or Proctectomy Code Code Type Description 44139 CPT Mobilization of Colon 44140 CPT Partial Removal of Colon 44141 CPT Partial Removal of Colon 44143 CPT Partial Removal of Colon 44144 CPT Partial Removal of Colon 44145 CPT Partial Removal of Colon 44146 CPT Partial Removal of Colon 44147 CPT Partial Removal of Colon 44150 CPT Removal of Colon 44151 CPT Removal of Colon/Ileostomy 44160 CPT Removal of Colon 44204 CPT Lap Partial Colectomy 44205 CPT Lap Colectomy Part w Ileum Page 5
44206 CPT Lap Part Colectomy w Stoma 44207 CPT L Colectomy/Colotostomy 44208 CPT L Colectomy/Colotostomy 44210 CPT Laparo Total Proctocolectomy 44213 CPT Lap - Mobil Splenic Fl Add-On 45110 CPT Removal of Rectum 45111 CPT Partial Removal of Rectum 45112 CPT Removal of Rectum 45113 CPT Partial Proctectomy 45114 CPT Partial Removal of Rectum 45116 CPT Partial Removal of Rectum 45119 CPT Remove Rectum w Reservoir 45123 CPT Partial Proctectomy 45126 CPT Pelvic Exenteration 45160 CPT Excision of Rectal Lesion 45170 CPT Excision of Rectal Lesion 45395 CPT Lap - Removal of Rectum 45397 CPT Lap - Remove Rectum w Pouch 45.40-45.49 ICD-9-PCS Procedure Local excision/destruction of lesion or tissue of large intestine 45.70-45.79 ICD-9-PCS Procedure Open and other partial excision of large intestine 45.8 ICD-9-PCS Procedure Total intra-abdominal colectomy 48.35 ICD-9-PCS Procedure Local excision of rectal lesion or tissue 48.36 ICD-9-PCS Procedure [Endoscopic] polypectomy of rectum 48.40-48.49 ICD-9-PCS Procedure Pull-through resection of rectum 48.5 ICD-9-PCS Procedure Abdominoperineal resection of rectum 48.60-48.69 ICD-9-PCS Procedure Other resection of rectum 48.80-48.89 ICD-9-PCS Procedure Incision or excision of perirectal tissue or lesion Page 6
CLF-C: Codes to Identify Post Resection of Colorectal Cancer Code Code Type Description 1530 ICD-9-CM Diagnosis Mal Neo Hepatic Flexure 1531 ICD-9-CM Diagnosis Mal Neo Transverse Colon 1532 ICD-9-CM Diagnosis Mal Neo Descend Colon 1533 ICD-9-CM Diagnosis Mal Neo Sigmoid Colon 1534 ICD-9-CM Diagnosis Malignant Neoplasm Cecum 1536 ICD-9-CM Diagnosis Malig Neo Ascend Colon 1537 ICD-9-CM Diagnosis Mal Neo Splenic Flexure 1538 ICD-9-CM Diagnosis Malignant Neo Colon NEC 1539 ICD-9-CM Diagnosis Malignant Neo Colon NOS 1540 ICD-9-CM Diagnosis Mal Neo Rectosigmoid Jct 1541 ICD-9-CM Diagnosis Malignant Neopl Rectum 1548 ICD-9-CM Diagnosis Mal Neo Rectum/Anus NEC 44139 CPT Mobilization of Colon 44140 CPT Partial Removal of Colon 44141 CPT Partial Removal of Colon 44143 CPT Partial Removal of Colon 44144 CPT Partial Removal of Colon 44145 CPT Partial Removal of Colon 44146 CPT Partial Removal of Colon 44147 CPT Partial Removal of Colon 44150 CPT Removal of Colon 44151 CPT Removal of Colon/Ileostomy 44160 CPT Removal of Colon 44204 CPT Laparo Partial Colectomy 44205 CPT Lap Colectomy Part w Ileum 44206 CPT Lap Part Colectomy w Stoma 44207 CPT L Colectomy/Colotostomy 44208 CPT L Colectomy/Colotostomy 44210 CPT Laparo Total Proctocolectomy Page 7
44213 CPT Lap - Mobil Splenic Fl Add-On 45110 CPT Removal of Rectum 45111 CPT Partial Removal of Rectum 45112 CPT Removal of Rectum 45113 CPT Partial Proctectomy 45114 CPT Partial Removal of Rectum 45116 CPT Partial Removal of Rectum 45119 CPT Remove Rectum w Reservoir 45123 CPT Partial Proctectomy 45126 CPT Pelvic Exenteration 45160 CPT Excision of Rectal Lesion 45170 CPT Excision of Rectal Lesion 45395 CPT Lap - Removal of Rectum 45397 CPT Lap - Remove Rectum w Pouch 454* ICD-9-PCS Procedure Local excision/destruction of lesion or tissue of large intestine 457* ICD-9-PCS Procedure Open and other partial excision of large intestine 458 ICD-9-PCS Procedure Total intra-abdominal colectomy 4835 ICD-9-PCS Procedure Local excision of rectal lesion or tissue 4836 ICD-9-PCS Procedure [Endoscopic] polypectomy of rectum 484* ICD-9-PCS Procedure Pull-through resection of rectum 485 ICD-9-PCS Procedure Abdominoperineal resection of rectum 486* ICD-9-PCS Procedure Other resection of rectum 488* ICD-9-PCS Procedure Incision or excision of perirectal tissue or lesion CLF-D: Codes to Identify Hospice Care Code Code Type Description V66.7 ICD-9-CM Diagnosis Encountr Palliative Care 99376 CPT Hospice 99377 CPT Hospice Care Supervision 99378 CPT Hospice Care Supervision G0065 HCPCS Hospice Care Plan Oversight Page 8
G0182 HCPCS Hospice Care Supervision G0337 HCPCS Hospice Evaluation Preelecti Q5001 HCPCS Hospice in Patient Home Q5002 HCPCS Hospice in Assisted Living Q5003 HCPCS Hospice in Lt/Non-Skilled Nf Q5004 HCPCS Hospice in Snf Q5005 HCPCS Hospice, Inpatient Hospital Q5006 HCPCS Hospice in Hospice Facility Q5007 HCPCS Hospice in Ltch Q5008 HCPCS Hospice in inpatient psych Q5009 HCPCS Hospice Care, NOS S0255 HCPCS Hospice refer visit nonmd S0271 HCPCS Home hospice case 30 days S9126 HCPCS Hospice Care - in the Home - P T2042 HCPCS Hospice Routine Home Care T2043 HCPCS Hospice Continuous Home Care T2044 HCPCS Hospice Respite Care T2045 HCPCS Hospice General Care T2046 HCPCS Hospice Long Term Care - R&b 0115 UB Revenue Hospice/PVT 0125 UB Revenue Hospice/2 BED 0135 UB Revenue Hospice 0145 UB Revenue Hospice/DLX 0155 UB Revenue Hospice/WARD 0235 UB Revenue Increm.Nursing Charge/Hospice 0650 UB Revenue Hospice 0651 UB Revenue Hospice/Routine Home Care 0652 UB Revenue Hospice/Continuous Home Care 0655 UB Revenue Hospice/Inpatient Respite Care 0656 UB Revenue Hospice/Inpatient Non Respite 0657 UB Revenue Hospice/Physician Services Page 9
0658 UB Revenue Hospice/R&B/Nursing Facility 0659 UB Revenue Other Hospice Service 81* UB Bill Type Special Facility, Hospice (non-hospital based) 82* UB Bill Type Special Facility, Hospice (hospital-based) 34 Place of Service Hospice CLF-E: Codes to Identify Colonoscopy, Sigmoidoscopy, or Protoscopy Code Code Type Description 3017F CPT Colorectal cancer screening results documented and reviewed 44388 CPT Colonoscopy 44389 CPT Colonoscopy w Biopsy 44390 CPT Colonoscopy for Foreign Body 44391 CPT Colonoscopy for Bleeding 44392 CPT Colonoscopy & Polypectomy 44393 CPT Colonoscopy - Lesion Removal 44394 CPT Colonoscopy w Snare 44397 CPT Colonoscopy w Stent 45330 CPT Diagnostic Sigmoidoscopy 45331 CPT Sigmoidoscopy & Biopsy 45332 CPT Sigmoidoscopy w FB Removal 45333 CPT Sigmoidoscopy & Polypectomy 45334 CPT Sigmoidoscopy for Bleeding 45335 CPT Sigmoidoscopy w Submuc Inj 45337 CPT Sigmoidoscopy & Decompress 45338 CPT Sigmoidoscopy w Tumr Remove 45339 CPT Sigmoidoscopy w Ablate Tumr 45340 CPT Sig w Balloon Dilation 45341 CPT Sigmoidoscopy w Ultrasound 45342 CPT Sigmoidoscopy w US Guide Bx 45345 CPT Sigmoidoscopy w Stent 45378 CPT Diagnostic Colonoscopy Page 10
45379 CPT Colonoscopy w FB Removal 45380 CPT Colonoscopy & Biopsy 45381 CPT Colonoscopy - Submucous Inj 45382 CPT Colonoscopy/Control Bleeding 45383 CPT Lesion Removal Colonoscopy 45384 CPT Lesion Remove Colonoscopy 45385 CPT Lesion Removal Colonoscopy 45386 CPT Colonoscopy Dilate Stricture 45387 CPT Colonoscopy w Stent 45391 CPT Colonoscopy w Endoscope US 45392 CPT Colonoscopy w Endoscopic Fnb S0601 CPT Screening Proctoscopy G0104 HCPCS CA Screen;flexi Sigmoidscope G0105 HCPCS Colorectal Scrn; Hi Risk Ind G0121 HCPCS Colon CA Scrn Not Hi Rsk Ind 4522 ICD-9-PCS Procedure Endoscopy of large intestine through artificial stoma 4523 ICD-9-PCS Procedure Colonoscopy 4524 ICD-9-PCS Procedure Flexible sigmoidoscopy 4525 ICD-9-PCS Procedure Closed [endoscopic] biopsy of large intestine 4542 ICD-9-PCS Procedure Endoscopic polypectomy of large intestine 4543 ICD-9-PCS Procedure Endoscopic destruction of other lesion/tissue of large intestine Page 11