American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association  (AGA)/Physician Consortiu...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association   (AGA)/Physician Consorti...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association  (AGA)/Physician Consortiu...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association  (AGA)/Physician Consortiu...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association  (AGA)/Physician Consortiu...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association  (AGA)/Physician Consortiu...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association  (AGA)/Physician Consortiu...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association  (AGA)/Physician Consortiu...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association  (AGA)/Physician Consortiu...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association  (AGA)/Physician Consortiu...
Endoscopy/Poly Surveillance          Measure #2: Colonoscopy Interval for Patients with a History of Adenomatous Polyps-  ...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association  (AGA)/Physician Consortiu...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association  (AGA)/Physician Consortiu...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association  (AGA)/Physician Consortiu...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician          C...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician          C...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician          C...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician          C...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician          C...
American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician          C...
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Endoscopy and Polyp Surveillance Physician Performance ...

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Endoscopy and Polyp Surveillance Physician Performance ...

  1. 1. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality Assurance Endoscopy and Polyp Surveillance Physician Performance Measurement Set Approved by the PCPI®-August 2008 Co-chairs John Allen, MD, MBA, AGAF (Gastroenterology) Doug Faigel, MD (Gastroenterology) Work Group Members Nancy Baxter, MD, PhD, FACRS, FACS (Colon and Rectal Surgery) Stephen Bickston, MD, AGAF (Gastroenterology) Joel V. Brill, MD, AGAF, FASGE, FACG, CHCQM (Gastroenterology) Kirk Brandon, MBA (Business Administration/Coding) Jason A. Dominitz, MD, MHS, AGAF (Gastroenterology) Ira L. Flax, MD, FACG (Gastroenterology) Karen E. Hall, MD, PhD (Geriatrics) Robert Haskey, MD, FACS (General Surgery, Health Plan representative) Brian C. Jacobson, MD, MPH (Gastroenterology) David Lieberman, MD (Gastroenterology) Klaus Mergener, MD, PhD, CPE, FACP, FACG, FASGE, FACPE (Gastroenterology) Bret Petersen, MD, FASGE (Gastroenterology) Irving M. Pike, MD, FACG (Gastroenterology) Bart Pope, MD (Family Medicine) Harry Sarles, MD, FACG (Gastroenterology) Kay Schwebke, MD, MPH (Specialty: Internal Medicine, Infectious Diseases & Medical Informatics) Tom Lynn, MD (Medical Informatics, Methodology) Emily E. Volk, MD, FCAP (Pathology) Michael Weinstein, MD Specialty: Gastroenterology) American Gastroenterological Association Debbie Robin, MSN, RN, CHCQM American Society for Gastrointestinal Endoscopy Jill Blim Chris Recker, RN, MPH Martha Espronceda American College of Gastroenterology Julie Cantor-Weinberg, MPP American Medical Association Joseph Gave, MPH Karen Kmetik, PhD Shannon Sims, MD, PhD Beth Tapper, MA Consortium Consultants Rebecca Kresowik Timothy Kresowik, MD© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 1CPT® Copyright 2007 American Medical Association
  2. 2. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality AssurancePhysician Performance Measures (Measures) and related data specifications developed by the American Medical Association(AMA) in collaboration with the Physician Consortium for Performance Improvement® (PCPI) and the National Committee forQuality Assurance (NCQA), pursuant to government sponsorship under Subcontract No. 6414-07-089 with Mathematica PolicyResearch under Contract HHSM-500-2005-000251(0004) with Centers for Medicare and Medicaid Services.These performance Measures are not clinical guidelines and do not establish a standard of medical care, and have not been testedfor all potential applications.The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., useby health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of theMeasures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed forcommercial gain. Commercial uses of the Measures require a license agreement between the user and the AMA, (on behalf of thePCPI) or NCQA. Neither the AMA, NCQA, PCPI nor its members shall be responsible for any use of the Measures.THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved.Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets shouldobtain all necessary licenses from the owners of these code sets. The AMA, NCQA, the PCPI and its members disclaim all liabilityfor use or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specifications.CPT® contained in the Measures specifications is copyright 2007 American Medical Association. LOINC® copyright 2004Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT®) copyright 2004 College of American Pathologists(CAP). All Rights Reserved. Use of SNOMED CT® is only authorized within the United States.© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 2CPT® Copyright 2007 American Medical Association
  3. 3. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality AssurancePurpose of Measures:These clinical performance measures, developed by the American Society for Gastrointestinal Endoscopy/AmericanGastroenterological Association/ Physician Consortium for Performance Improvement® (Consortium)/NationalCommittee for Quality Assurance (NCQA), are designed for individual quality improvement. Unless otherwiseindicated, the measures are also appropriate for accountability if appropriate methodological, statistical, andimplementation rules are achieved.Measures:Measure # 1: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk PatientsMeasure #2: Colonoscopy Interval for Patients with a History of Adenomatous Polyps- Avoidance of InappropriateUseMeasure # 3: Comprehensive Colonoscopy DocumentationIntended Audience and Patient Population:These measures are designed for use by physicians and for calculating reporting or performance measurement at theindividual clinician level. When existing hospital-level or plan-level measures are available for the samemeasurement topics, the Consortium attempts to harmonize the measures to the extent feasible.Measures 1 through 3 are designed for any clinician caring for patients aged 18 years and older receiving colonoscopyprocedures.Measure SpecificationsThe Consortium seeks to specify measures for implementation using multiple data sources, including paper medicalrecord, administrative (claims) data, and particular emphasis on Electronic Health Record Systems (EHRS). Draftspecifications to report on these measures for Endoscopy using administrative (claims) data are included in thisdocument. We have identified codes for these measures, including ICD-9 and CPT (Evaluation & ManagementCodes, Category I and where Category II codes would apply). Specifications for additional data sources, includingEHRS, will be fully developed at a later date.Measure Exclusions:For process measures, the Consortium provides three categories of reasons for which a patient may be excluded fromthe denominator of an individual measure: • Medical reasons Includes: - not indicated (absence of organ/limb, already received/performed, other) - contraindicated (patient allergic history, potential adverse drug interaction, other) • Patient reasons Includes: - patient declined - economic, social, or religious reasons - other patient reasons • System reasons Includes: - resources to perform the services not available - insurance coverage/payor-related limitations - other reasons attributable to health care delivery systemThese measure exclusion categories are not available uniformly across all measures; for each measure, there must be aclear rationale to permit an exclusion for a medical, patient, or system reason. The exclusion of a patient may bereported by appending the appropriate modifier to the CPT Category II code designated for the measure: • Medical reasons: modifier 1P • Patient reasons: modifier 2P • System reasons: modifier 3P© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 3CPT® Copyright 2007 American Medical Association
  4. 4. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality AssuranceAlthough this methodology does not require the external reporting of more detailed exclusion data, the Consortiumrecommends that clinicians document the specific reasons for exclusion in patients’ medical records for purposes ofoptimal patient management and audit-readiness. The Consortium also advocates the systematic review and analysisof each physician’s exclusions data to identify practice patterns and opportunities for quality improvement. Forexample, it is possible for implementers to calculate the percentage of patients that physicians have identified asmeeting the criteria for exclusion.Please refer to documentation for each individual measure for information on the acceptable exclusion categories andthe codes and modifiers to be used for reporting.Measures #1-3 in the Endoscopy/Polyp Surveillance measurement set are process measures.For outcome measures, the Consortium specifically identifies all acceptable reasons for which a patient may beexcluded from the denominator. Each specified reason is reportable with a CPT Category II code designated for thatpurpose.There are no outcome measures in the Endoscopy/Polyp Surveillance measurement set.The Consortium continues to evaluate and likely will evolve its methodology for handling exclusions as it gainsexperience in the use of the measures. The Consortium welcomes comments on its exclusions methodology.Data Capture and Measure CalculationThe Consortium intends for clinicians to collect data on each patient eligible for a measure. Feedback on measuresshould be available to clinicians by patient to facilitate patient management and in aggregate to identify opportunitiesfor improvement across a clinicians patient population.Measure calculations will differ depending on whether a rate is being calculated for performance or reportingpurposes.The method of calculation for performance follows these steps: first, identify the patients (or reports) who meet theeligibility criteria for the denominator (PD); second, identify which of those patients (or reports) meet the numeratorcriteria (A); and third, for those patients (or reports) who do not meet the numerator criteria, determine whether anappropriate exclusion applies and subtract those patients from the denominator (C). (see examples below)The methodology also enables implementers to calculate the rates of exclusions and to further analyze both low andhigh rates, as appropriate (see examples below).The method of calculation for reporting differs. One program which currently focuses on reporting rates is theCenters for Medicare and Medicaid Services (CMS) Physician Quality Reporting Initiative (PQRI). Currently, underthat program design, there will be a reporting denominator determined solely from claims data (CPT and ICD-9),which in some cases result in a reporting denominator that is much larger than the eligible population for theperformance denominator. Additional components of the reporting denominator are explained below.The components that make up the numerator for reporting include all patients/reports from the eligible population forwhich the physician has reported, including: the number of patients/reports who meet the numerator criteria (A), thenumber of patients/reports for whom valid exclusions apply (C) and also the number of patients/reports who do notmeet the numerator criteria (D). These components, where applicable, are summed together to make up the inclusivereporting numerator. The calculation for reporting will be the reporting numerator divided by the reportingdenominator. (see examples below).Examples of calculations for reporting and performance are provided for each measure. Calculation for Performance For performance purposes, this measure is calculated by creating a fraction with the following components: Numerator, Denominator, and Denominator Exclusions.© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 4CPT® Copyright 2007 American Medical Association
  5. 5. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality Assurance Numerator (A) Includes: Number of patients meeting numerator criteria Performance Denominator (PD) Includes: Number of patients meeting criteria for denominator inclusion Denominator Exclusions (C) Include: Number of patients with valid medical, patient or system exclusions (where applicable; will differ by measure) Performance Calculation A (# of patients meeting numerator criteria) PD (# patients in denominator) – C (# patients with valid denominator exclusions) It is also possible to calculate the percentage of patients excluded overall, or excluded by medical, patient, or system reason where applicable: Overall Exclusion Calculation C (# of patients with any valid exclusion) PD (# patients in denominator) OR Exclusion Calculation by Type C1 (# patients with C2 (# patients with C3 (# patients with medical reason) patient reason) system reason) PD (# patients in denominator) PD (# patients in denominator) PD (# patients in denominator) Calculation for Reporting For reporting purposes, this measure is calculated by creating a fraction with the following components: Reporting Numerator and Reporting Denominator Reporting Numerator includes each of the following components, where applicable. (There may be instances where there are no patients to include in A, C, D, or E). A. Number of patients meeting additional denominator criteria (for measures where true denominator cannot be determined through ICD-9 and CPT Category I coding alone) AND numerator criteria C. Number of patients with valid medical, patient or system exclusions (where applicable; will differ by measure) D. Number of patients not meeting numerator criteria and without a valid exclusion E. All other patients not meeting additional denominator criteria (for measures where true denominator cannot be determined through ICD-9 and CPT Category I coding alone)© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 5CPT® Copyright 2007 American Medical Association
  6. 6. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality Assurance Reporting Denominator (RD) Includes: RD. Denominator criteria (identifiable through ICD-9 and CPT Category I coding) Reporting Calculation A(# of patients meeting additional denominator criteria AND numerator criteria) + C(# of patients with valid exclusions) + D(# of patients NOT meeting numerator criteria) + E(# of patients not meeting additional denominator criteria) RD (# of patients in denominator)© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 6CPT® Copyright 2007 American Medical Association
  7. 7. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality Assurance Endoscopy/Poly Surveillance Measure #1: Appropriate follow-up interval for normal colonoscopy in average risk patients This measure may be used as an Accountability measure Clinical Performance MeasureNumerator: Patients who had a recommended follow-up interval of at least 10 years for repeat colonoscopydocumented in their colonoscopy reportDenominator: All patients aged 50 years and older receiving screening colonoscopy without biopsy orpolypectomyDenominator Exclusion:Documentation of medical reason(s) for not recommending at least a 10 year follow-up interval (eg, above averagerisk patient, inadequate prep)Measure: Percentage of patients aged 50 years and older receiving a screening colonoscopy without biopsy orpolypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented intheir colonoscopy report.The following clinical recommendation statements are quoted verbatim from the referenced clinicalguidelines and represent the evidence base for the measure:Colonoscopy is recommended approximately every 10 years for average-risk individuals (Davila et al, 2006). Thecompleteness of the examination and the quality of the preparation should be taken into account for the timing ofsubsequent examinations. After a good-quality colonoscopy examination without findings of colon cancer oradenomatous polyps is performed, further screening tests (eg, FOBT) should not be done for approximately 10 years( Davila et al, 2006).Rationale for the measure:In the average-risk population, colonoscopy screening is recommended in all current guidelines at 10-year intervals.Inappropriate interval recommendations can result in overuse of resources and can lead to significant patient harm.Performing colonoscopy too often not only increases patients’ exposure to procedural harm, but also drainsresources that could be more effectively used to adequately screen those in need (Lieberman et al, 2008). The mostcommon serious complication of colonoscopy is post-polypectomy bleeding (Levin et al, 2008).Variations in the recommended time interval between colonoscopies exist for patients with normal colonoscopyfindings. In a 2006 study of 1282 colonoscopy reports, recommendations were consistent with contemporaneousguidelines in only 39.2% of cases and with current guidelines in 36.7% of cases. Further, the adjusted mean numberof years in which repeat colonoscopy was recommended was 7.8 years following normal colonoscopy( Krist et al,2007).Data capture and calculations:Calculation for PerformanceFor performance purposes, this measure is calculated by creating a fraction with the following components:Numerator, Denominator, and Denominator Exclusions.Performance Numerator (A) Includes: • Patients who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy reportPerformance Denominator (PD) Includes:© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 7CPT® Copyright 2007 American Medical Association
  8. 8. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality Assurance • All patients aged 50 years and older receiving screening colonoscopy without biopsy or polypectomyPerformance Denominator Exclusions (C) Include: • Documentation of medical reason(s) for not recommending at least a 10 year follow-up interval (eg, above average risk patient, inadequate prep) Performance Calculation A (# of patients meeting measure criteria) PD (# of patients in denominator) - C (# of patients with valid denominator exclusions)Components for this measure are defined as: A # of patients who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report PD # of patients aged 50 years and older receiving screening colonoscopy without biopsy or polypectomy C # of patients who have a documentation of medical reason(s) for not recommending a 10 year follow-up interval (eg, above average risk patient, inadequate prep)Calculation for ReportingFor reporting purposes, this measure is calculated by creating a fraction with the following components: ReportingNumerator and Reporting DenominatorReporting Numerator includes each of the following instances:A. Patients who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented intheir colonoscopy reportC. Patients who did not have a recommended follow-up interval of at least 10 years for repeat colonoscopydocumented in their colonoscopy report, but for whom there is a documented medical reason for not doing soD. Patients who did not have a recommended follow-up interval of at least 10 years for repeat colonoscopydocumented in their colonoscopy report and there is no documented reason for not doing soReporting Denominator (RD) Includes: • All patients aged 50 years and older receiving screening colonoscopy without biopsy or polypectomy Reporting Calculation A(# of patients meeting numerator criteria) + C(# of patients with valid exclusions) + D(# of patients NOT meeting numerator criteria) RD (# of patients in denominator)Components for this measure are defined as: A # of patients who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report C # of patients who did not have a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report, but for whom there is a documented© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 8CPT® Copyright 2007 American Medical Association
  9. 9. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality Assurance medical reason for not doing so D # of patients who did not have a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report and there is no documented reason for not doing so RD # of patients aged 50 years and older receiving screening colonoscopy without biopsy or polypectomy© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 9CPT® Copyright 2007 American Medical Association
  10. 10. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality AssuranceMeasure Specifications – Measure #1: Appropriate follow-up interval for normal colonoscopy in average riskpatientsMeasure specifications for data sources other than administrative claims will be developed at a later date. A. Administrative claims data Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible population/denominator criteria. (Note: The specifications listed below are those needed for performance calculation. Additional CPT Category II codes may be required based on measure implementation [ie, if measure is utilized in a reporting program]). Physicians who indicate that the colonoscopy procedure is incomplete or was discontinued should use the procedure number and the addition (as appropriate) of modifier 52, 53, 73 or 74. Patients who have a coded colonoscopy procedure that has modifier 52, 53, 73 or 74 will not qualify for inclusion into this measure. Denominator (Eligible Population): All patients aged 50 years and older receiving screening colonoscopy without biopsy or polypectomy • CPT code or G-Code: G0121, 45378 CPT code with a modifier of -52, -53, -73 or -74 will not be included in the denominator of this measure Numerator: Patients who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report • Report the CPT Category II code designated for this numerator: 0528F- Recommended follow-up interval for repeat colonoscopy of at least 10 years documented in colonoscopy report Denominator Exclusion: Documentation of medical reason(s) for not recommending at least a 10-year follow-up interval (eg, above average risk patient, inadequate prep) • Append modifier to CPT Category II code: 0528F-1P B. Electronic Health Record System (in development) C. Paper Medical Record (in development)© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 10CPT® Copyright 2007 American Medical Association
  11. 11. Endoscopy/Poly Surveillance Measure #2: Colonoscopy Interval for Patients with a History of Adenomatous Polyps- Avoidance of Inappropriate Use This measure may be used as an Accountability measure Clinical Performance MeasureNumerator: Patients who had an interval of 3 or more years since their last colonoscopyDenominator: All patients aged 18 years and older receiving a surveillance colonoscopy with a history of a priorcolonic polyp in a previous colonoscopyDenominator Exclusions: • Documentations of medical reason(s) for an interval of less than 3 years since the last colonoscopy (eg, patients with high risk for colon cancer, last colonoscopy incomplete, last colonoscopy had inadequate prep, piecemeal removal of adenomas, or last colonoscopy found greater than 10 adenomas) • Documentation of a system reason(s) for an interval of less than 3 years since the last colonoscopy (eg, unable to locate previous colonoscopy report)Measure: Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a priorcolonic polyp in previous colonoscopy findings who had a follow-up interval of 3 or more years since their lastcolonoscopy documented in the colonoscopy reportThe following clinical recommendation statements are quoted verbatim from the referenced clinical guidelinesand represent the evidence base for the measure:Patients with 1 to 2 small (1 cm) tubular adenomas with only low-grade dysplasia should undergo follow-upcolonoscopy no earlier than 5 years later. Patients with advanced adenomatous lesions or >3 adenomas should haverepeat colonoscopy in 3 years as long as all visualized polyps were completely removed, the colonoscopy wascompleted up to the cecum, and the colonic preparation was adequate. A shorter interval of follow-up is recommendedin those patients with numerous adenomatous (>10) polyps and in those in whom the colonoscopy was incomplete orthe preparation was inadequate. After a surveillance colonoscopy has normal results, repeat examinations should bedone at 5-year intervals. Patients with large, sessile adenomatous lesions removed in a piecemeal fashion should have arepeat examination within 2 to 6 months to exclude and remove and remnant polypoid tissue (Grade 1a) (Davila et al,2006)Rationale for the measure:Colonoscopy is the recommended method of surveillance after the removal of adenomatous polyps because it has beenshown to significantly reduce subsequent Colorectal Cancer incidence. The timing of follow-up colonoscopy should betailored to the number, size, and pathologic findings of the adenomatous polyps removed. The time interval for thedevelopment of malignant changes in adenomatous polyps is estimated at 5 to 25 years (ICSI, 2006). A randomizedcontrolled trial of 699 patients showed that after newly diagnosed adenomatous polyps have been removed bycolonoscopy, follow-up colonoscopy at 3 years detects important colonic lesions as effectively as follow-upcolonoscopy at both 1 and 3 years (ICSI, 2006).Performing colonoscopy too often not only increases patients’ exposure to procedural harm, but also drains limitedresources that could be more effectively used to adequately screen those in need. Recent evidence from 4 surveysindicated that postpolypectomy surveillance colonoscopy in the United States is frequently performed at intervals thatare shorter than those recommended in guidelines (Rex et al, 2006). Some endoscopists in these studies performedcolonoscopy in patients with only small hyperplastic polyps or a single tubular adenoma at 1 year. These surveysunderscore the importance of measuring intervals between examinations in continuous quality improvement programs.© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved.CPT® Copyright 2007 American Medical Association
  12. 12. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality Assurance Data capture and calculations: Calculation for Performance For performance purposes, this measure is calculated by creating a fraction with the following components: Numerator, Denominator, and Denominator Exclusions. Performance Numerator (A) Includes: • Patients who had an interval of 3 or more years since their last colonoscopy Performance Denominator (PD) Includes: • All patients aged 18 years and older receiving a surveillance colonoscopy with a history of a prior colonic polyp in a previous colonoscopy Performance Denominator Exclusions (C) Include: • Documentation of medical reason(s) for an interval of less than 3 years since the last colonoscopy (eg, patients with high risk for colon cancer, last colonoscopy incomplete, last colonoscopy had inadequate prep, piecemeal removal of adenomas, or last colonoscopy found greater than 10 adenomas) • Documentation of a system reason(s) for an interval of less than 3 years since the last colonoscopy (eg, unable to locate previous colonoscopy report, previous colonoscopy report was incomplete) Performance Calculation A (# of patients meeting measure criteria) PD (# of patients in denominator) - C (# of patients with valid exclusions) Components for this measure are defined as: A # of patients who had an interval of 3 or more years since their last colonoscopy PD # of patients aged 18 years and older receiving a surveillance colonoscopy with a history of a prior colonic polyp in a previous colonoscopy C # of patients with documentation of medical reason(s) for an interval of less than 3 years since the last colonoscopy (eg, patients with high risk for colon cancer, last colonoscopy incomplete, last colonoscopy had inadequate prep, piecemeal removal of adenomas, or last colonoscopy found greater than 10 adenomas) OR patients with documentation of a system reason(s) for an interval of less than 3 years since the last colonoscopy (eg, unable to locate previous colonoscopy report, previous colonoscopy report was incomplete)Calculation for ReportingFor reporting purposes, this measure is calculated by creating a fraction with the following components: ReportingNumerator and Reporting DenominatorReporting Numerator includes each of the following instances:A. Patients who had an interval of 3 or more years since their last colonoscopyC. Patients who did not have an interval of 3 or more years since their last colonoscopy, but for whom there is adocumented medical or system reason for not doing so.D. Patients who did not have an interval of 3 or more years since their last colonoscopy and there is no documentedreason for not doing so© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 12CPT® Copyright 2007 American Medical Association
  13. 13. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality AssuranceReporting Denominator (RD) Includes:All patients aged 18 years and older receiving a surveillance colonoscopy with a history of a prior colonic polyp in aprevious colonoscopy Reporting Calculation A(# of patients meeting numerator criteria) + C (# of patients with valid exclusions) + D(# of patients NOT meeting numerator criteria) RD (# of patients in denominator)Components for this measure are defined as: A # of patients who had an interval of 3 or more years since their last colonoscopy C # of patients who did not have an interval of 3 or more years since their last colonoscopy, but for whom there is a documented medical or system reason for not doing so. D # of patients who did not have an interval of 3 or more years since their last colonoscopy and there is no documented reason for not doing so RD # of patients aged 18 years and older receiving a surveillance colonoscopy with a history of a prior colonic polyp in a previous colonoscopy© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 13CPT® Copyright 2007 American Medical Association
  14. 14. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality AssuranceMeasure Specifications – Measure #2: Surveillance Colonoscopy Interval for Patients with a History of ColonicPolyps- Avoidance of Inappropriate Use A. Administrative claims data Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible population/denominator criteria. (Note: The specifications listed below are those needed for performance calculation. Additional CPT Category II codes may be required based on measure implementation [ie, if measure is utilized in a reporting program]). Physicians who indicate that the colonoscopy procedure is incomplete or was discontinued should use the procedure number and the addition (as appropriate) of modifier 52, 53, 73 or 74. Patients who have a coded colonoscopy procedure that has modifier 52, 53, 73 or 74 will not qualify for inclusion into this measure. Denominator (Eligible Population): All patients aged 18 years and older receiving a surveillance colonoscopy with a history of a prior colonic polyp in a previous colonoscopy • ICD-9-CM diagnosis code: V12.72 AND • CPT codes or G-Codes: 44388, 44389, 44392, 44393, 44394, 45355, 45378, 45380, 45381, 45383, 45384, 45385, G0105 CPT codes with a modifier of -52, -53, -73 or -74 will not be included in the denominator of this measure Numerator: Patients who had an interval of 3 or more years since their last colonoscopy • Report the CPT Category II code designated for this numerator: 0529F- Interval of at least 3 or more years since patient’s last colonoscopy, documented • Denominator Exclusion: Documentations of medical reason(s) for an interval of less than 3 years since the last colonoscopy (eg, last colonoscopy incomplete, last colonoscopy had inadequate prep, piecemeal removal of adenomas, or last colonoscopy found greater than 10 adenomas) • Append modifier to CPT Category II code: 0529F-1P Documentation of a system reason(s) for an interval of less than 3 years since the last colonoscopy (eg, unable to locate previous colonoscopy report, previous colonoscopy report was incomplete) • Append modifier to CPT Category II code: 0529F-3P B. Electronic Health Record System (in development) C. Paper Medical Record (in development)© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 14CPT® Copyright 2007 American Medical Association
  15. 15. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality Assurance Endoscopy/Polyp Surveillance Measure #3: Comprehensive Colonoscopy Documentation This measure may be used as an Accountability measure Clinical Performance MeasureNumerator: Final reports that include documentation of ALL of the following: • Pre-procedure risk assessment (eg, ASA class, Mallampati score) • Depth of insertion (i.e., to cecum or other landmark) • Quality of the bowel prep (ie, prep was either adequate or inadequate) • Complete description of polyp(s) found, including location of each polyp, size, number and gross morphology • Recommendations for follow-upDenominator: All final colonoscopy reports for patients aged 18 years and olderDenominator Exclusions: NoneMeasure: Percentage of final colonoscopy reports for patients aged 18 years and older that include documentationof all of the following: pre-procedure risk assessment; depth of insertion; quality of the bowel prep; completedescription of polyp(s) found, including location of each polyp, size, number and gross morphology; andrecommendations for follow-upThe following clinical recommendation statements are quoted verbatim from the referenced clinicalguidelines and represent the evidence base for the measure:Before sedation is begun, a risk assessment is performed to stratify patients into higher or lower-risk-for-complications groups (particularly as pertains to sedation) [Grade 1C] (Faigel et al, 2006). The physician/nurse teamshould document the risk assessment. (Risk stratification systems commonly used are the ASA score and theMallampati score). Visualization of the cecum by notation of landmarks and photo documentation of landmarksshould be documented in every procedure (Grade 1C). Most important, these include the appendiceal orifice and theileocecal valve. There should be documentation in the procedure note of the quality of the preparation of the bowel(Grade 2C) (Faigel et al, 2006). In clinical trials of bowel preparation, terms used to commonly characterize bowelpreparation include ‘‘excellent,’’ ‘‘good,’’ ‘‘fair,’’ and ‘‘poor.’’ In clinical practice, these terms do not havestandardized definitions. In clinical trials on the effectiveness of various regimens for bowel preparation, excellentis typically defined as no or minimal solid stool and only small amounts of clear fluid requiring suctioning. ‘‘Good’’is typically no or minimal solid stool with large amounts of clear fluid requiring suctioning. ‘‘Fair’’ refers tocollections of semisolid debris that are cleared with difficulty. ‘‘Poor’’ refers to solid or semisolid debris that cannotbe effectively cleared. The endoscopist should be prepared to perform a total examination and remove all polypsfound at the time of the first colonoscopy, although technical factors encountered during colonoscopy may limitcompletion of the procedure (Davila et al, 2006).© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 15CPT® Copyright 2007 American Medical Association
  16. 16. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality AssuranceRationale for the measure:The goal of this measure is to ensure appropriate documentation of colonoscopy findings and recommendations.The desired outcome is diminished risks to patients and cost savings from a reduction in inappropriatecolonoscopies.• Pre-procedure risk assessment is often used as a surrogate of co-morbidity; research has shown an association between higher class and adverse events. The Clinical Outcomes Research Initiative (CORI) on Colonoscopy Quality Indicators Study of 53 gastroenterology practice sites in 24 states looked at all patients undergoing colonoscopy (n=438,521); in this study, documentation of risk assessment was measured. The ASA Classification field was not completed in 10.1% of reports. In 10 of 53 sites, completion rates were less than 90%. When completed, 7.0% of exams were performed in high-risk individuals with ASA class 3 or higher (Lieberman et al, 2008).• The need for cecal intubation is based on the continual finding that a substantial number of colorectal neoplasms are located in the proximal colon, including the cecumError! Bookmark not defined.. Numerous studies have shown that physicians routinely do not document the depth of insertion in the colonoscopy report. Quality evaluation of the colon consists of intubation of the entire colon and a detailed mucosal inspection. Cecal intubation improves sensitivity and reduces costs by eliminating the need for radiographic procedures or repeat colonoscopy to complete examination. Careful mucosal inspection is essential to effective colorectal cancer prevention and reduction of cancer mortality.• Poor bowel preparation is a major impediment to the effectiveness of colonoscopy and impacts the ability to detect polyps and influences the timing of repeat examinations. Poor preparation prolongs cecal intubation time and withdrawal time and reduces detection of both small and large polyps (Faigel et al, 2006). The economic burden of repeating examinations because of inadequate bowel preparation is substantial. The Clinical Outcomes Research Initiative (CORI) on Colonoscopy Quality Indicators Study of 53 gastroenterology practice sites in 24 states looked at all patients undergoing colonoscopy (n=438,521); in this study, quality of bowel prep recorded was assessed. Findings indicated that 13.9% of reports did not have bowel prep quality reported and in 14 of 53 practices, over 20% did not have bowel prep quality (Lieberman et al, 2008).• Accurate polyp descriptions are essential to assess disease progression and inform timing of repeat colonoscopy. The timing of follow-up colonoscopy should be tailored to the number, size, and pathologic findings of the adenomatous polyps removed. Gaps in care exist in this aspect of documentation. A recent multi-center study looked at variations in practice and assessed the quality of colonoscopy procedures. Findings indicated that polyp size not recorded in 4.9% of polyps, polyp morphology (pedunculated, sessile, flat) was not reported in 14.7% of reported polyps, and polyp retrieval and submission to pathology was not documented in 4.5% of polyps (Lieberman et al, 2008). These gaps in the documentation of the description of the polyps removed during colonoscopy underscore the need to improve physician adherence to quality patient care.• Recent evidence suggests that surveillance colonoscopy for post-polypectomy patients in the United States is frequently performed at intervals that are shorter than those recommended in guidelines. In addition, many patient records do not have a recommended follow-up interval recorded. For example, in a 2006 study of 1282 colonoscopy reports, recommendations were consistent with contemporaneous guidelines in only 39.2% of cases and with current guidelines in 36.7% of cases. Correspondence from the endoscopist included no guidance on follow-up testing in 33.5% of cases (Krist et al, 2007).Data capture and calculations:Calculation for PerformanceFor performance purposes, this measure is calculated by creating a fraction with the following components:Numerator and Denominator.Performance Numerator (A) Includes: • Final reports that include documentation of ALL of the following: Pre-procedure risk assessment (eg, ASA class, Mallampati score); Depth of insertion (i.e., to cecum or other landmark); Quality of the bowel prep (ie, prep was either adequate or inadequate); Complete description of polyp(s) found, including location of each polyp, size, number and gross morphology; Recommendations for follow-upPerformance Denominator (PD) Includes: • All final colonoscopy reports for patients aged 18 years and older© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 16CPT® Copyright 2007 American Medical Association
  17. 17. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality Assurance Performance Calculation A (# of reports meeting numerator criteria) PD (# of reports in denominator)Components for this measure are defined as: A #of final reports that include documentation of ALL of the following: Pre-procedure risk assessment (eg, ASA class, Mallampati score); Depth of insertion; Quality of the bowel prep (ie, prep was either adequate or inadequate); Complete description of polyp(s) found, including location of each polyp, size, number and gross morphology; Recommendations for follow-up PD # of final colonoscopy reports for patients aged 18 years and olderCalculation for ReportingFor reporting purposes, this measure is calculated by creating a fraction with the following components: ReportingNumerator and Reporting Denominator.Reporting Numerator includes each of the following instances:A. Final colonoscopy reports that include documentation of ALL of the following: Pre-procedure risk assessment(eg, ASA class, Mallampati score); Depth of insertion; Quality of the bowel prep (ie, prep was either adequate orinadequate); Complete description of polyp(s) found, including location of each polyp, size, number and grossmorphology; Recommendations for follow-upD. Final colonoscopy reports that do not include documentation of the ALL of the following: Pre-procedure riskassessment (eg, ASA class, Mallampati score); Depth of insertion; Quality of the bowel prep (ie, prep was eitheradequate or inadequate); Complete description of polyp(s) found, including location of each polyp, size, number andgross morphology; Recommendations for follow-upReporting Denominator (RD) Includes: • All final colonoscopy reports for patients aged 18 years and older Reporting Calculation A(# of reports meeting numerator criteria ) + D(# of reports NOT meeting numerator criteria) + RD (# of reports in denominator)Components for this measure are defined as: A # of colonoscopy reports that include documentation of ALL of the following: Pre-procedure risk assessment (eg, ASA class, Mallampati score); Depth of insertion; Quality of the bowel prep (ie, prep was either adequate or inadequate); Complete description of polyp(s) found, including location of each polyp, size, number and gross morphology; Recommendations for follow-up D # of final colonoscopy reports that do not include documentation of the ALL of the following: Pre-procedure risk assessment (eg, ASA class, Mallampati score); Depth of insertion; Quality of the bowel prep (ie, prep was either adequate or inadequate); Complete description of polyp(s) found, including location of each polyp, size, number and gross morphology; Recommendations for follow-up RD # of final colonoscopy reports for patients aged 18 years and older© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 17CPT® Copyright 2007 American Medical Association
  18. 18. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality AssuranceMeasure Specifications – Measure #3: Comprehensive Colonoscopy DocumentationMeasure specifications for data sources other than administrative claims will be developed at a later date. A. Administrative claims data Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible population/denominator criteria. (Note: The specifications listed below are those needed for performance calculation. Additional CPT Category II codes may be required based on measure implementation [ie, if measure is utilized in a reporting program]). Physicians who indicate that the colonoscopy procedure is incomplete or was discontinued should use the procedure number and the addition (as appropriate) of modifier 52, 53, 73 or 74. Patients who have a coded colonoscopy procedure that has modifier 52, 53, 73 or 74 will not qualify for inclusion into this measure. Denominator (Eligible Population): All final colonoscopy reports for patients aged 18 years and older • CPT Codes or G-Codes: 44388, 44389, 44390, 44391, 44392, 44393, 44394, 44397, 45355, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45386, 45387, 45391, 45392, G0105, G0121 CPT codes with a modifier of -52, -53, -73 or -74 will not be included in the denominator of this measure Numerator: Final reports that include documentation of ALL of the following: Pre-procedure risk assessment (eg, ASA class, Mallampati score); Depth of insertion; Quality of the bowel prep (ie, prep was either adequate or inadequate); Complete description of polyp(s) found, including location of each polyp, size, number and gross morphology; Recommendations for follow-up • Report the CPT Category II code designated for this numerator: 3018F- Pre-procedure risk assessment AND depth of insertion AND quality of the bowel prep AND complete description of polyp(s) found, including location of each polyp, size, number and gross morphology AND recommendations for follow-up in final colonoscopy report, documented Denominator Exclusion: None© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 18CPT® Copyright 2007 American Medical Association
  19. 19. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality Assurance EVIDENCE CLASSIFICATIONS / RATING SCHEMES ASGE/ACG Quality Indicators for Endoscopic Procedures/Esophagogastroduodenoscopy/Colonoscopy/Endoscopic Retrograde Cholangiopancreatography/Endoscopic Ultrasonography Grades of RecommendationGrade of Clarity of Methodologic strength/Supporting ImplicationsRecommendation Benefit evidence 1A Clear Randomized trials without important Strong recommendation: can be limitations applied to most clinical settings 1B Clear Randomized trials with important Strong recommendation; likely to limitations (inconsistent results, apply to most practice settings nonfatal methodologic flaws) 1C+ Clear Overwhelming evidence from Strong recommendation; can apply to observational studies most practice settings in most situations 1C Clear Observational studies Intermediate-strength recommendation; may change when stronger evidence is available 2A Unclear Randomized trials without important Intermediate strength limitations recommendation; best action may differ depending on circumstances or patients’ or societal values 2B Unclear Randomized trials with important Weak recommendation; alternative limitations (inconsistent results, non approaches may be better under some fatal methodological flaws) circumstances 2C Unclear Observational studies Very weak recommendation; alternative approaches likely to be better under some circumstances 3 Unclear Expert opinion only Weak recommendation; likely to change as data become availableICSI Conclusion Grades • Grade I: The evidence consists of results from studies of strong design for answering the question addressed. The results are both clinically important and consistent with minor exceptions at most. The results are free of any significant doubles about generalizability, bias, and flaws in research design. Studies with negative results have sufficiently large samples to have adequate statistical power. • Grade II: The evidence consists of results from studies of strong design for answering the question addressed, but there is some uncertainty attached to the conclusion because of inconsistencies among the results from the studies or because of minor doubts about generalizability, bias, research design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from weaker designs for the questions addressed, but the results have been confirmed in separate studies and are consistent with minor exceptions at most. • Grade III: The evidence consists of results from studies of strong design for answering the question addressed, but there is substantial uncertainty attached to the conclusion because of inconsistencies among the results from different studies or because of serious doubts about generalizability, bias, research design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from a limited number of studies of weak design for answering the question addressed.American College of Gastroenterology Ratings of Evidence • Level of Evidence I: Strong evidence from at least one published systematic review of multiple well- designed randomized controlled trials • Level of Evidence II: Strong evidence from at least one published properly designed randomized controlled trial of appropriate size and in an appropriate clinical setting© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 19CPT® Copyright 2007 American Medical Association
  20. 20. American Society for Gastrointestinal Endoscopy (ASGE)/American Gastroenterological Association (AGA)/Physician Consortium for Performance Improvement® (PCPI)/National Committee for Quality Assurance • Level of Evidence III: Evidence from published well-designed trials without randomization, single group prepost, cohort, time series, or matched case-controlled studies. • Level of Evidence IV: Evidence from well-designed nonexperimental studies from more than one center or research group or opinion of respected authorities, based on clinical evidence, descriptive studies, or reports of consensus committeesReferencesDavila , R, Rajan, E, Baron, T. American Society for Gastrointestinal Endoscopy. ASGE guideline: colorectal cancerscreening and surveillance. Vol. 63. No.4; 2006.Faigel, DO, Pike, IM, Baron, TH, et al. ASGE/ACG Taskforce on Quality in Endoscopy. Quality Indicators ForGastrointestinal Endoscopic Procedures: An Introduction. Gastrointestinal Endoscopy. Volume 63, No. 4 : 2006.Institute for Clinical Systems Improvement (ICSI). Colorectal cancer screening. Bloomington (MN): Institute forClinical Systems Improvement (ICSI); 2006 Jun. 50 p.Krist, AH, jones, RM, Woolf, SH et al. Timing of Repeat Colonoscopy: Disparity Between Guidelines andEndoscopists’ Recommendation. American Journal of Preventive Medicine. 2007Levin B, Lieberman DA, McFarland B et al. Screening and Surveillance for the Early Detection of Colorectal Cancerand Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the US Multi-Society TaskForce on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin 2008. March 5.Lieberman, DA, Faigel, DO, Logan, J, Mattek, N, Holub, J, Eisen, G, Morris, C, Smith, R, Nadel, M. Assessment ofColonoscopy Quality: Results from a multi-center consortium. In Press. 2008© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved. 20CPT® Copyright 2007 American Medical Association

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