Colorectal Cancer Screening (COL‑E) 2025

HEDIS^® (Healthcare Effectiveness Data Information Set) is a widely used set of performance measures developed and maintained by NCQA. These are used to drive improvement efforts surrounding best practices.

The HEDIS quality measures reported using the Electronic Clinical Data Systems (ECDS) inspire innovative use of electronic clinical data to document high‑quality patient care that demonstrates commitment to evidence‑based practices. Organizations that report HEDIS using ECDS encourage the electronic exchange of the information needed to provide high‑quality services, ensuring that the information reaches the right people at the right time.

HEDIS measure

This measure assesses the percentage of patients ages 45 to 75 on a Medicare Advantage plan who had an appropriate screening for colorectal cancer.

Numerator

Patients with one or more screenings for colorectal cancer. Any of the following meet 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
• CT colonography during the measurement period or the four years prior to the measurement period
• Stool DNA (sDNA) with fecal immunochemical test (FIT) test during the measurement period or the two years prior to the measurement period

Denominator (eligible patients):

Members 46 to 75 years as of the end of the measurement period who also meet the criteria for participation. Member must have continuous medical enrollment during the measurement period and the year prior to the measurement period

Exclusions:

• Patients 66 years of age and older as of December 31 of the measurement year (all product lines) with frailty and advanced illness; patients must meet both frailty and advanced illness criteria to be excluded
• Patients receiving palliative care any time during the measurement year
• Patients who had an encounter for palliative care any time during the measurement year. Do not include laboratory claims (claims with POS code 81).
• Patients who had colorectal cancer any time during the patient’s history through December 31 of the measurement year. Do not include laboratory claims (claims with POS code 81).
• Patients who had a total colectomy any time during the patient’s history through December 31 of the measurement period
• Patients who use hospice services or elect to use a hospice benefit any time during the measurement year
• Patients who die any time during the measurement year

Closing the gap

Documentation needed:

• Colonoscopy in 2016 through 2025 (10 years):
• CPT^®: 44388‑44392, 44394, 44397, 44401‑44408, 45378‑45393, 45398
• HCPCS: G0105, G0121
• Flexible sigmoidoscopy in 2021 through 2025 (five years):
• CPT: 45330‑45335, 45337, 45338, 45340 ‑ 45342, 45346, 45347, 45349, 45350
• HCPCS: G0104
• Computed tomography (CT) colonography in 2021 through 2025 (five years):
• CPT: 74261‑74263
• Fecal immunochemical test (FIT)‑DNA (for example, Cologuard^®) in 2023 through 2025 (three years):
• CPT: 81528
• Fecal occult blood test (FOBT) during the measurement year with results reported by a lab:
• CPT: 82270, 82274
• HCPCS: G0328
• Fecal immunochemical test (FIT)‑non-DNA (for example, InSure^® ONE™) or fecal occult blood test (FOBT) in 2024 (one year):
• CPT: 82270, 82274
• HCPCS: G0328

Medical record documentation that meets criteria:

• Date, type of screening, and result
• Date and type of screening in medical history/health maintenance section
• Pathology report indicating date and type of screening

Notes: Do not count digital rectal exams (DRE), FOBT performed in an office setting or on a sample collected via a DRE, epi ProColon^® methylated Septin 9 gene detection blood test, or ColoCARE^®. Two patient identifiers are required.

Best practices:

• Schedule colonoscopy for the patient January to October to increase the likelihood of completion.
• Educate patients scheduled for colonoscopy on co‑pay and side effects of prep kits.
• Educate staff on low‑cost prep options (such as Miralax) for those who encounter barriers.
• Encourage patients who resist a colonoscopy to complete an at‑home stool test (FOBT, FIT‑non-DNA, FIT‑DNA).
• Educate, order, and/or distribute FOBT, FIT‑Non-DNA or FIT‑DNA kits to patients who need a colorectal cancer screening. Remind patient of expiration date of kit.
• Provide test prior to the visit and encourage it be returned at visit.
• Follow up on all colorectal screenings ordered and ensure testing was completed.
• When documenting a colorectal screening, identify the date and type of screening.
• Scan the colonoscopy report into the medical record.
• Outreach to patients via phone calls instead of letters, as this method yields better results.

Let’s work together

Measure is closed via:

• Claims
• Consolidated Clinical Document Architecture (CCDA)
• SFTP/flat files
• Cotiviti

Please visit My Diverse Patients for additional information about eLearning experiences on provider cultural competency and health equity. You can also visit https://www.anthem.com/provider/individual-commercial/medicare-advantage.