A family practice we work with pulled its registry in the first week of March and found 812 patients between 45 and 75 with no colorectal cancer screening on record. That was 31 percent of the eligible panel. The physicians were surprised, because they ask about screening at every annual visit. The registry was not wrong. About a third of those patients had a colonoscopy documented somewhere in a scanned GI note without a structured date, another third had never come in for an annual visit, and the rest had been handed a stool test kit and never returned it.
March is Colorectal Cancer Awareness Month, which is why the screening posters go up, and it is also the month when plans have finished their year-end quality reports and start sending the new year's care gap lists. If you are going to run one colorectal cancer screening gap closure push in 2026, March is when the data is freshest and the calendar still has room to get a colonoscopy scheduled before December.
This article covers how the HEDIS Colorectal Cancer Screening measure counts, which tests close a gap and for how long, the codes that get them paid and recognized, and the tiered outreach plan we run with small practices.
Key takeaways
- The measure covers adults 45 to 75; the age dropped from 50 for measurement year 2022 after the USPSTF May 2021 recommendation.
- Five tests count, with lookbacks from one year (FIT) to ten years (colonoscopy), so a patient can be "screened" in your chart and still open on the plan's list if the date is not structured or the test is old.
- Most open gaps are data gaps: outside colonoscopies without a structured date, or kits handed out and never returned.
- For Medicare patients in 2026, a screening colonoscopy that turns diagnostic carries 15 percent coinsurance with modifier PT, and a follow-on colonoscopy after a positive stool test is a screening with modifier KX.
- A mailed FIT kit with two reminder calls is the cheapest gap closer a small practice has; colonoscopy referral needs closed-loop tracking or it leaks.
How the measure counts
The HEDIS Colorectal Cancer Screening measure (COL, now reported through electronic clinical data as COL-E) is the percentage of members 45 to 75 who had an appropriate screening. NCQA expanded the age range from 50 to 75 down to 45 to 75 for measurement year 2022, following the U.S. Preventive Services Task Force recommendation of May 2021, which gave screening at 45 to 49 a B grade and at 50 to 75 an A grade. Plans report it for commercial, Medicare and Medicaid lines, and it is a Medicare Advantage Star Ratings measure, which is why Medicare Advantage plans chase it hardest.
The numerator accepts five tests, each with its own lookback. A colonoscopy counts if performed in the measurement year or the nine years before it. CT colonography and flexible sigmoidoscopy count for the measurement year or the four years before. A multi-target stool DNA test (Cologuard is the common brand) counts for the measurement year or the two years before. A fecal occult blood test, which in practice means a fecal immunochemical test (FIT) or the older guaiac test, counts only if done during the measurement year. Blood-based screening tests are not in the numerator under the current specifications, so a blood test may satisfy a Medicare coverage rule and still leave the HEDIS gap open; check the specification for the year you are reporting.
Exclusions matter too. Patients with a history of colorectal cancer or a total colectomy are excluded, as are patients in hospice or palliative care and, for Medicare, patients 66 and older with advanced illness and frailty. A registry that does not apply the exclusions overstates your gap; a registry that applies them from unstructured notes understates it.
| Test | Counts for HEDIS if done within | Medicare screening code and frequency | Common CPT for commercial | Practical note |
|---|---|---|---|---|
| Colonoscopy | Measurement year plus 9 prior years | G0121 average risk every 10 years; G0105 high risk every 2 years | 45378 and the polypectomy family (45380, 45385) with modifier 33 | Needs a structured date in the chart; a scanned note does not count until abstracted |
| CT colonography | Measurement year plus 4 prior years | 74263, covered by Medicare as a screening from January 1, 2025 | 74263 | Useful for patients who refuse colonoscopy and cannot do stool tests |
| Flexible sigmoidoscopy | Measurement year plus 4 prior years | G0104 every 4 years | 45330 | Rarely used now but still counts |
| Multi-target stool DNA (FIT-DNA) | Measurement year plus 2 prior years | 81528 every 3 years, ages 45 to 85 | 81528 | Vendor ships and processes; result must flow back to the chart |
| FIT or gFOBT | Measurement year only | G0328 (FIT) or 82270 (gFOBT) annually | 82274 (FIT), 82270 (gFOBT) | Annual; the gap reopens every January |
Colorectal cancer screening gap closure starts with the list
Start from your own registry, not the plan's list. The plan sees claims; you see the chart. Pull every active patient aged 45 to 75 at the end of 2026 with no structured colonoscopy in the last ten years, no CT colonography or sigmoidoscopy in the last five, no FIT-DNA in the last three and no FIT this year. Then remove the exclusions. That is your true open list.
Then reconcile it against the gap lists from your top three plans. Patients on the plan's list but not yours usually mean your chart has a screening the plan never saw: a colonoscopy done before the patient joined the plan, or one billed under a facility claim the plan did not map. For those, the fix is data, not a test. Most plans accept supplemental data, a spreadsheet or portal upload of member, test, date and CPT, and will close the gap without a visit. Patients on your list but not the plan's are usually exclusions the plan applied that you did not, or patients who changed plans.
The practice in the opening paragraph cut its 812 to 540 in two weeks this way: 190 outside colonoscopies were abstracted into structured fields from scanned GI reports, and 82 patients were excluded or had left the practice. No patient was contacted yet.
Tiered outreach a small practice can run
Tier one is the annual visit. Every patient on the list who has a visit scheduled in the next 90 days gets a flag; the medical assistant hands the FIT kit or places the FIT-DNA order during rooming, before the physician walks in, and the physician's job is only to answer questions. In our experience the completion rate roughly doubles when the kit goes home from a visit rather than being mailed cold.
Tier two is mailed FIT for patients with no upcoming visit who are average risk and have no contraindication documented. A kit, a prepaid return envelope and a one-page letter signed by the patient's own physician, followed by a reminder call or text at two weeks and again at four. Published mailed-FIT programs report return rates from roughly 30 percent to well above 50 percent depending on the reminders, and the lab cost is low. Set a rule that an unreturned kit at eight weeks triggers one phone call and then a note to discuss at the next visit, so kits do not sit open forever on the list.
Tier three is colonoscopy referral for patients who are high risk, who had a positive stool test, or who prefer it. This tier leaks. A referral placed is not a screening done; the patient has to be scheduled, prepped, seen, and the report has to come back and be abstracted. Track it as a closed-loop referral with a due date and a person who calls the GI office at 30 days if no report has arrived. The same closed-loop discipline we use for closing gaps in care generally applies here, and PCMH-recognized practices already have the referral tracking criteria in place to hang it on.
Billing notes that prevent patient complaints
Patients complain about colorectal screening bills more than any other preventive service, and it is almost always a modifier. For commercial plans, a screening colonoscopy that becomes diagnostic when a polyp is removed should carry modifier 33 so the plan applies preventive benefits with no cost sharing under the Affordable Care Act. For Medicare, the equivalent is modifier PT, and for 2026 the patient still owes 15 percent coinsurance on the diagnostic portion; that falls to 10 percent for 2027 through 2029 and to zero from 2030 under the Consolidated Appropriations Act of 2021 schedule. Tell the patient that in advance, in writing, at the referral.
Since January 1, 2023, Medicare treats a colonoscopy performed because of a positive stool-based screening test as a screening, not a diagnostic service, so the deductible does not apply; the GI practice appends modifier KX to signal it. Make sure your referral tells the GI office the colonoscopy follows a positive FIT or FIT-DNA so they code it that way. And make sure the FIT you bill to Medicare uses G0328, not 82274, or it will deny as a non-covered lab.
Questions we hear
A patient had a colonoscopy in 2019 at a hospital we have no record from. Does it count?
Yes, if performed in 2017 or later for measurement year 2026, and if you can document the date. Ask the patient or the GI practice for the report, enter the date in a structured field, and send it to the plan as supplemental data. A patient's verbal report with a year is accepted by many plans for supplemental data if it is documented in the chart with the date the patient stated; check each plan's supplemental data rules.
Should we switch everyone to FIT-DNA because it lasts three years?
Not everyone. The three-year interval helps the measure and the patient, and the vendor handles shipping and reminders. Against that, the test costs the payer considerably more than a FIT, has a higher false-positive rate, and every positive requires a colonoscopy. We suggest FIT-DNA for patients who have failed to return FIT kits, and FIT for those who complete them. Cost sharing varies by plan, so check before ordering for commercial patients.
What do we do about the 45 to 49 group who have never been asked?
Treat them as a distinct outreach cohort. Many of these patients do not think of themselves as screening age, so the letter has to say the age changed in 2021. In our experience this cohort responds well to mailed FIT because they are working, do not want a procedure, and appreciate a test they can do at home.
What to do this week
- Pull the registry for patients 45 to 75 with no qualifying screening within the lookbacks, and apply the exclusions.
- Reconcile against the gap lists from your top three plans and send supplemental data for any screening the plan has not seen.
- Assign a medical assistant to abstract dates from scanned outside colonoscopy reports into the structured field, 20 charts a day.
- Flag every listed patient with a visit in the next 90 days so the kit or order happens at rooming.
- Set up the mailed FIT batch for patients without a visit, with reminder calls scheduled at two and four weeks.
- Confirm the billing team uses G0328 for Medicare FIT and that GI referrals after a positive stool test say so on the order.
