PRINCIPAL ACCOUNTABLE PROVIDER MANUAL

Transcription

1 Health Care Payment Improvement Building a healthier future for all Arkansans Arkansas Payment Improvement Initiative Episodes of Care PRINCIPAL ACCOUNTABLE PROVIDER MANUAL Colonoscopy Episode Reimbursement Program MPI /17 Arkansas Blue Cross and Blue Shield AHCPII Help Desk APIICustomerSupport@arkbluecross.com Last Update: May 10, 2018 Arkansas Blue Plans in this report refers to Arkansas Blue Cross and Blue Shield, Health Advantage and/or BlueAdvantage Administrators of Arkansas.

2 Colonoscopy Episode Reimbursement Program The Arkansas Health Care Payment Improvement Initiative (AHCPII) was developed as a joint effort between Arkansas Medicaid, QualChoice and Arkansas Blue Cross and Blue Shield, its affiliates and subsidiaries (Arkansas Blue Cross). More information may be found within this manual or at The Colonoscopy Episode Program will incentivize better coordination of care, encourage clinical effectiveness, and reward high quality care in order to reduce complications that threaten quality and increase costs. Episode Definition A core component of this program is episodes of care. An episode is the collection of care provided to treat a particular condition over a given length of time. The colonoscopy episode includes all care related to the procedure. A colonoscopy episode spans from 30 days prior to the procedure to 30 days after the procedure. Included in the episode are all facility services, professional services, as well as any related labs and diagnostics, outpatient costs, and medications. Principal Accountable Provider (PAP) For each episode, the provider that holds the main responsibility for ensuring that care is delivered at appropriate cost and quality will be designated as the PAP based on observed patterns of care. The PAP for the colonoscopy episode is the physician performing the colonoscopy procedure. The PAP for each episode is identified retrospectively through claims data. As leaders, however, PAPs will share in the savings and excess costs of episodes. A provider must have five or more eligible cases of an episode to be considered a PAP. For example, a physician must have performed at least five eligible colonoscopy episodes. The provider billing for the service on the claim is held responsible in the episode calculations. For this reason accurate coding is essential. Claims Submission Claims filing procedures will be the same as they are today as described in Arkansas Blue Cross Provider Network Agreements and provider manuals. Supplemental Quality Measures In order to participate in upside savings, providers must meet: 1. A quality metric related to the 30-day readmission rate using the same re-admission criteria as CMS. 2. Additionally, PAPs will receive reports highlighting their performance on cecalintubation rate, average withdrawal time, intestinal perforation rate, and post-polypectomy/ biopsy bleed rate, if applicable, for each patient must be entered via the AHIN portal in order for the PAP to participate in sharing any applicable savings. GIQuIC Registry Pilot for For providers participating in GIQuIC (GI Quality Improvement Consortium, Ltd.), Arkansas Blue Cross and Blue Shield is piloting a new process for capturing Colonoscopy Episode of Care Quality Information. Arkansas Blue Cross

3 recognizes that participating in a benchmarking registry initiative like GIQuIC requires facilities to establish the processes for tracking and reporting in an efficient and reliable manner, and readies facilities for future quality and performance expectations. Principal Accountable Providers (PAPs) that participate in the GIQuIC registry may supply their year-end report to satisfy the portal entry requirements. Submission of the GIQuIC registry information for the reporting time period (January - December 2017) to the APIICustomerSupport@arkbluecross.com address will suffice for documentation. Arkansas Blue Cross will review the GIQuIC reports and manually update the quality metrics for these providers. If you have questions about our Colonoscopy Episode of Care or the GIQuLC registry pilot, please contact the Arkansas Blue Cross Episodes of Care Analyst Team at or APIICustomerSupport@arkbluecross.com. Adjustments and Exclusions Reference the Colonoscopy Algorithm Summary for details. Reports for Principal Accountable Providers (PAPs) Reference the AHCPII Overview Page within this manual for details and instructions on accessing the PAP Reports on the Provider Portal. Financial Settlements in the Episodes of Care Model Reference the AHCPII Overview Page within this manual for details on the Financial Settlement Process. Provider Appeal Process Reference the AHCPII Overview Page within this manual for details on the Provider Appeal Process. This Program document is referenced in the provider agreements and amendments (defined as ("Program") of the Preferred Payment Plan, True Blue PPO, Arkansas' First Source PPO and Health Advantage Network Participating Provider Agreements. Therefore it is considered to be part of these agreements. Colonoscopy Algorithm Summary

4 Colonoscopy Algorithm Summary v1.6 Page 2 of 18 Triggers PAP assignment Exclusions An episode is triggered when a patient shows a claim with a Colonoscopy CPT procedure code. For specific ICD-9-CM, DRG, and CPT/HCPCS procedure codes, please see dataset. The Principal Accountable Provider (PAP) for an episode is the physician enrolled in an Arkansas Blue Plan provider network who performs the Colonoscopy procedure. Episodes meeting one or more of the following criteria will be excluded: A. The patient has claims or enrollment records that indicate coordination of benefits with another payer not associated with the Arkansas Blue Plans within the duration of the episode B. The patient does not have continuous coverage with at least one Arkansas Blue Plan throughout the entire episode C. The overall episode cost for the patient exceeds the outlier criteria. Currently, the outlier threshold is set at three standard deviations above the average episode cost for all patients otherwise included in the reporting period for all PAPs D. The episode window overlaps with another episode E. Procedure occurred late in the performance period, episode will likely appear on next report F. Provider terminated prior to report publication G. The patient was discharged against medical advice or due to expiration. H. Patient was pregnant during episode I. Patient less than 18 years old J. Patient 65 years or older K. Patient claims indicate one of the following comorbidities within 365 days before the episode: 1) Abortion complications, 2) Complications from organ transplants, 3) Dialysis, 4) Ileostomy, 5) Colostomy and enterostomy, 6) Colonoscopy via colotomy, 7) Colostomy or skin level cecostomy, 8) Laparoscopic surgical colostomy, 9) Select organ transplants (kidney, heart), 10) ESRD (end-stage renal disease), 11) Perinatal jaundice, 12) Respiratory distress, 13) Inflammatory bowel disease, 14) Bone cancer, 15) Brain cancer, 16) Bronchial/lung cancer, 17) Colon cancer, 18) Esophageal cancer, 19) GI/peritoneum cancer, 20) Liver cancer, 21) Malignant neoplasm, 22) Neoplasm unspecified, 23) Female genital cancer, 24) Male genital cancer, 25) Ovarian cancer, 26) Pancreas cancer, 27) Rectum/anus cancer, 28) Kidney/renal cancer, 29) Stomach cancer, 30) Urinary organ cancer, 31) Secondary malignancy, 32) Other respiratory cancer, 33) Other primary cancer, 34) Fetal disturbances, 35) Forceps or vacuum extractor delivery, 36) Malposition, 37) Other perinatal diagnosis, 38) Umbilical cord complications, 39) Spontaneous abortion, 40) Suicide and intentional self-inflicted injury, 41) Gallbladder cancer, 42) Endoscopy L. Patient is an Exchange member M. Patient is an Access Only member N. Patient had an Appendectomy during the episode window O. Non-par self-insured groups: ABB Inc. (ABB/Baldor and Thomas & Betts), Green Bay Packaging, Hytrol Conveyor Co, Inc, Mana, Nabholz Inc, Navistar Inc, NYSC NYS Holding Company (Nucor), Replacement Parts, Riceland Foods Inc, Southern Steel & Wire (effective 1/1/16), and White River Medical Center

5 Colonoscopy Algorithm Summary v1.6 Page 3 of 18 Episode time If the procedure is determined as screening based on procedure codes, the episode begins on the date of the trigger procedure and ends 30 window days after the trigger procedure. Claims included Quality measures Adjustments Trigger codes If the episode is determined as diagnostic based on procedure codes, the episode begins with the first service performed by the PAP within 30 days prior to the trigger procedure and ends 30 days after the trigger procedure. The following services are included if incurred within the episode: A. Inpatient facility claims for admit date within 30 days after the trigger procedure, even if discharge is after 30 days. Claims with a DRG on the CMS list of exclusions for Gastrointestinal procedures will not be included in the episode. B. Include all claims in the episode window related to the Colonoscopy procedure as defined in the procedure, diagnosis and NDC lists for the entire window C. Include all claims in the episode window after the trigger procedure related to a potentially avoidable condition as defined in the procedure, diagnosis and NDC list for post-procedure window Quality measures to pass (payment related): A. Cecal intubation rate PAP will enter in quality metrics on all required randomly selected prospective episodes. The PAP also has the opportunity to enter in quality metrics for optional episodes, if they so choose. Only included episodes will be considered for the rate calculation. Must meet a minimum threshold of 75% episodes. B. Withdrawal time PAP will enter in quality metrics on all required randomly selected prospective episodes. The PAP also has the opportunity to enter in quality metrics for optional episodes, if they so choose. Only included episodes will be considered for the rate calculation. Must meet a minimum threshold of 80% of episodes. Quality measures to track (not payment related): A. Perforation rate calculated based on diagnosis codes with the same date as the trigger procedure date B. Post polypectomy/biopsy bleed rate based on diagnoses on any claim during the episode window The total reimbursements attributed to the PAP will be adjusted based on complications that resulted in variations in treatment using a multiplier determined by regression. Over time, risk factors may be added or subtracted based on new research and/or empirical evidence. Claims with following codes are considered when triggering an episode: Diagnostic procedures: CPT: 45378, 45379, 45380, 45381, 45383, 45384, 45385, 45391, ICD-9: 45.23, 45.25, 45.27, ICD-10: 0DJD8ZZ, 0D9E3ZX, 0D9E3ZZ, 0DB80ZX, 0DBE4ZZ Screening procedures: CPT: G0105, G0121

6 Colonoscopy Algorithm Summary v1.6 Page 4 of 18 Exclusion Patients who have co-morbid condition(s) indicated by the following ICD-9-CM codes will be excluded: codes ICD-9-CM codes: , 150.0, 150.1, 150.2, 150.3, 150.4, 150.5, 150.8, 150.9, 151.0, 151.1, 151.2, 151.3, 151.4, 151.5, 151.6, 151.8, 151.9, 152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 153.0, 153.1, 153.2, 153.3, 153.4, 153.5, 153.6, 153.7, 153.8, 153.9, 154.0, 154.1, 154.2, 154.3, 154.8, 155.0, 155.1, 155.2, 156, 156.0, 156.0, 156.1, 156.1, 156.2, 156.8, 156.9, 157.0, 157.1, 157.2, 157.3, 157.4, 157.8, 157.9, 158.0, 158.8, 158.9, 159.0, 159.1, 159.8, 159.9, 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 163.0, 163.1, 163.8, 163.9, 164.0, 164.1, 164.2, 164.3, 164.8, 164.9, 165.0, 165.8, 165.9, 170.0, 170.1, 170.2, 170.3, 170.4, 170.5, 170.6, 170.7, 170.8, 170.9, 171.0, 171.2, 171.3, 171.4, 171.5, 171.6, 171.7, 171.8, 171.9, 176.0, 176.1, 176.2, 176.3, 176.4, 176.5, 176.8, 176.9, 181, 183.0, 183.2, 183.3, 183.4, 183.5, 183.8, 183.9, 184.0, 184.1, 184.2, 184.3, 184.4, 184.8, 184.9, 187.1, 187.2, 187.3, 187.4, 187.5, 187.6, 187.7, 187.8, 187.9, 189.0, 189.1, 189.2, 189.3, 189.4, 189.8, 189.9, 190.0, 190.1, 190.2, 190.3, 190.4, 190.5, 190.6, 190.7, 190.8, 190.9, 191.0, 191.1, 191.2, 191.3, 191.4, 191.5, 191.6, 191.7, 191.8, 191.9, 192.0, 192.1, 192.2, 192.3, 192.8, 192.9, 194.0, 194.1, 194.3, 194.4, 194.5, 194.6, 194.8, 194.9, 195.1, 195.2, 195.3, 195.4, 195.5, 195.8, 196.0, 196.1, 196.2, 196.3, 196.5, 196.6, 196.8, 196.9, 197.0, 197.1, 197.2, 197.3, 197.4, 197.5, 197.6, 197.7, 197.8, 198.0, 198.1, 198.2, 198.3, 198.4, 198.5, 198.6, 198.7, , , , 199.0, 199.1, 199.2, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 230.1, 230.2, 230.3, 230.4, 230.5, 230.6, 230.7, 230.8, 230.9, 231.1, 231.2, 231.8, 231.9, 233.3, , , , , 233.5, 233.6, 233.9, 234.0, 234.8, 234.9, 235.0, 235.1, 235.2, 235.3, 235.4, 235.5, 235.6, 235.7, 235.8, 235.9, 236.0, 236.1, 236.2, 236.3, 236.4, 236.5, 236.6, 236.7, , , , 237.0, 237.1, 237.2, 237.3, 237.4, 237.5, 237.6, 237.7, , , , , , 237.9, 238.0, 238.1, 238.2, 238.3, 238.4, 238.5, 238.6, 238.7, , , , , , , , , 238.8, 238.9, 239.0, 239.1, 239.2, 239.3, 239.4, 239.5, 239.6, 239.7, 239.8, , , 239.9, 443, 443.0, 443.2, , , 555, 555.0, 555.1, 555.2, 555.9, 556, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 585.5, 585.6, 630, 631, 631.0, 631.8, 632, 633, 633.0, , , 633.1, , , 633.2, , , 633.8, , , 633.9, , , 634, 634.0, , , , , 634.1, , , , 634.2, , , , 634.3, , , , 634.4, , , , 634.5, , , , 634.6, , , , , 634.7, , , , 634.8, , , , 634.9, , , , , , , , , , , , , , , , , , , , , , , , Patients who have co-morbid condition(s) indicated by the following ICD-9-CM codes will be excluded: ICD-9-CM codes: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 638.0, 638.1, 638.2, 638.3, 638.4, 638.5, 638.6, 638.7, 638.8, 638.9, 639, 639.0, 639.1, 639.2, 639.3, 639.4, 639.5, 639.6, 639.8, 639.9, 640, 640.0, , , , 640.8, , , , 640.9, , , , 641, 641.0, , , , 641.1, , , , 641.2, , , , 641.3, , , , 641.8, , , , 641.9, , , , 642, 642.0, , , , , , 642.1, , , , , , 642.2, , , , , ,

7 Colonoscopy Algorithm Summary v1.6 Page 5 of 18 Exclusion ICD-9-CM codes: 642.3, , , , , , 642.4, , , , , , 642.5, , , , codes , , 642.6, , , , , , 642.7, , , , , , 642.9, , , , (continued) , , 643, 643.0, , , , 643.1, , , , 643.2, , , , 643.8, , , , 643.9, , , , 644, 644.0, , , 644.1, , , 644.2, , , 645, 645.1, , , , 645.2, , , , 646, 646.0, , , , 646.1, , , , , , 646.2, , , , , , 646.3, , , , 646.4, , , , , , 646.5, , , , , , 646.6, , , , , , 646.7, , , , 646.8, , , , , , 646.9, , , , 647, 647.0, , , , , , 647.1, , , , , , 647.2, , , , , , 647.3, , , , , , 647.4, , , , , , 647.5, , , , , , 647.6, , , , , , 647.8, , , , , , 647.9, , , , , , 648, 648.0, , , , , , 648.1, , , , , , 648.2, , , , , , 648.3, , , , , , 648.4, , , , , , 648.5, , , , , , 648.6, , , , , , 648.7, , , , , , 648.8, , , , , , 648.9, , , , , , 649, 649.0, , , , , , 649.1, , , , , , 649.2, , , , , , 649.3, , , , , , 649.4, , , , , , 649.5, , , , 649.6, , , , , , 649.7, , , , 649.8, , , 650, 651, 651.0, , , , 651.1, , , , 651.2, , , , 651.3, , , , 651.4, , , , 651.5, , , , 651.6, , , , 651.7, , , , 651.8, , , , 651.9, , , , 652, 652.0, , , , , 652.1, , , , Patients who have co-morbid condition(s) indicated by the following ICD-9-CM codes will be excluded: ICD-9-CM codes: 652.2, , , , 652.3, , , , 652.4, , , , 652.5, , , , 652.6, , , , 652.7, , , , 652.8, , , , 652.9, , , , 653, 653.0, , , , 653.1, , , , 653.2, , , , 653.3, , , , 653.4, , , , 653.5, , , , 653.6, , , , 653.7, , , , 653.8, , , , 653.9, , , , 654, 654.0, , , , , , 654.1, , , , , , 654.2, , , , 654.3, , , , , , 654.4, , , , , , 654.5, , , , , , 654.6, , , , , , 654.7, , , , , , 654.8, , , , , , 654.9, , , , , , 655, 655.0, , , , 655.1, , , , 655.2, , , , 655.3, , , , 655.4, , , , 655.5, , , , 655.6, , , , 655.7, , , , 655.8, , , , 655.9, , , , 656, 656.0, , , , 656.1, , , , 656.2, , , , 656.3, , , , 656.4, , , , 656.5, , , , 656.6, , , , 656.7, , , , 656.8, , , , 656.9, , , , 657, ,657.01, , 658, 658.0, , , , 658.1, , , , 658.2, , , , 658.3, , , , 658.4, ,

8 Colonoscopy Algorithm Summary v1.6 Page 6 of 18 Exclusion ICD-9-CM codes: , , 658.8, , , , 658.9, , , , 659, 659.0, , , , 659.1, codes , , , 659.2, , , , 659.3, , , , 659.4, , , 659.5, , , (continued) , 659.6, , , , 659.7, , , , 659.8, , , , 659.9, , , , 660, 660.0, , , , , , , 660.2, , , , 660.3, , , , 660.4, , , , 660.5, , , , 660.6, , , , 660.7, , , , 660.8, , , , 660.9, , , , 661, 661.0, , , , , 661.1, , , , 661.2, , , , 661.3, , , , , 661.4, , , , , 661.9, , , , 662, 662.0, , , , 662.1, , , , 662.2, , , , 662.3, , , , 663, 663.0, , , , 663.1, , , , 663.2, , , , 663.3, , , , 663.4, , , , 663.5, , , , 663.6, , , , 663.8, , , , 663.9, , , , 664, 664.0, , , , 664.1, , , , 664.2, , , , 664.3, , , , 664.4, , , , 664.5, , , , 664.6, , , , 664.8, , , , 664.9, , , , 665, 665.0, , , , 665.1, , , 665.2, , , , 665.3, , , , 665.4, , , , 665.5, , , , 665.6, , , , 665.7, , , , , 665.8, , , , , , 665.9, , , , , , 666, 666.0, Patients who have co-morbid condition(s) indicated by the following ICD-9-CM codes will be excluded: ICD-9-CM codes: , , , 666.1, , , , 666.2, , , , 666.3, , , , 667, 667.0, , , , 667.1, , , , 668, 668.0, , , , , , 668.1, , , , , , 668.2, , , , , , 668.8, , , , , , 668.9, , , , , , 669, 669.0, , , , , , 669.1, , , , , , 669.2, , , , , , 669.3, , , , 669.4, , , , , , 669.5, , , 669.6, , , 669.7, , , 669.8, , , , , , 669.9, , , , , , 760.0, 760.1, 760.2, 760.3, 760.4, 760.5, 760.6, , , , , , , , , , , 760.8, 760.9, 761.0, 761.1, 761.2, 761.3, 761.4, 761.5, 761.6, 761.7, 761.8, 761.9, 762.0, 762.1, 762.2, 762.3, 762.4, 762.5, 762.6, 762.7, 762.8, 762.9, 763.0, 763.1, 763.2, 763.3, 763.4, 763.5, 763.6, 763.7, 763.8, , , , , , 763.9, 766.0, 766.1, 766.2, , , 769, 770.0, 770.1, , , , , , , , , , 770.2, 770.3, 770.4, 770.5, 770.6, 770.7, 770.8, , , , , , , , , 770.9, 771.0, 771.1, 771.2, 771.3, 771.4, 771.5, 771.6, 771.7, 771.8, , , , 772.0, 772.1, , , , , , 772.2, 772.3, 772.4, 772.5, 772.6, 772.8, 772.9, 773.0, 773.1, 773.2, 773.3, 773.4, 773.5, 774.0, 774.1, 774.2, , , , 774.4, 774.5, 774.6, 774.7, 775.0, 775.1, 775.2, 775.3, 775.4, 775.5, 775.6, 775.7, 775.8, , , 775.9, 776.0, 776.1, 776.2, 776.3, 776.4, 776.5, 776.6, 776.7, 776.8, 776.9, 777.1, 777.2, 777.3, 777.4, 777.5, , , , , 777.6, 777.8, 777.9, 778.0, 778.1, 778.2, 778.3, 778.4, 778.5, 778.6, 778.7, 778.8, 778.9, 779.0, 779.1, 779.2, 779.3, , , , , 779.4, 779.6, 779.7, 779.8, , , , , , 779.9, , , , 789.7, 795.1, , , , , , , , , , , , , 996.8, E950, E950.0, E950.1, E950.2, E950.3, E950.4, E950.5, E950.6, E950.7, E950.8, E950.9, E951, E951.0, E951.1, E951.8, E952, E952.0, E952.1, E952.8, E952.9, E953, E953.0, E953.1, E953.8, E953.9, E954, E955, E955.0, E955.1,

9 Colonoscopy Algorithm Summary v1.6 Page 7 of 18 Exclusion codes (continued) ICD-9-CM codes: E955.2, E955.3, E955.4, E955.5, E955.6, E955.7, E955.9, E956, E957, E957.0, E957.1, E957.2, E957.9, E958, E958.0, E958.1, E958.2, E958.3, E958.4, E958.5, E958.6, E958.7, E958.8, E958.9, V10.00, V10.03, V10.04, V10.05, V10.06, V10.07, V10.09, V10.11, V10.12, V10.20, V10.22, V10.29, V10.40, V10.43, V10.44, V10.45, V10.48, V10.49, V10.50, V10.52, V10.53, V10.59, V10.81, V10.84, V10.85, V10.86, V10.88, V10.89, V10.9, V10.90, V10.91, V13.7, V22, V22.0, V22.1, V22.2, V23, V23.0, V23.1, V23.2, V23.3, V23.4, V23.41, V23.42, V23.49, V23.5, V23.7, V23.8, V23.81, V23.82, V23.83, V23.84, V23.85, V23.86, V23.87, V23.89, V23.9, V24, V24.0, V24.1, V24.2, V27, V27.0, V27.1, V27.2, V27.3, V27.4, V27.5, V27.6, V27.7, V27.9, V42.0, V42.1, V42.5, V42.7, V45.1, V45.1, V45.11, V45.12, V50.2, V55.2, V55.3, V56, V56.0, V56.1, V56.2, V56.3, V56.31, V56.32, V56.8, V62.84, V71.1 Patients who have claims including any of the following ICD-9 procedure codes will be excluded: Procedure codes: 45.22, 46.1, 46.10, 46.11, 46.13, 46.14, 46.2, 46.20, 46.21, 46.22, 46.23, Patients who have claims including any of the following ICD-10 procedure codes will be excluded: Procedure codes: 0DJD8ZZ, 0D1H07H, 0D1H0Z4, 0D1H0Z4, 0H87XZZ, 0D1B07B, 0D1B0Z4, 0D1BZ4 0D1B8Z4, 0D1B0Z4, 0D1B4Z4, 0D1B8Z4, 0H87XZZ Patients with the following CPT/HCPCS procedure codes will be excluded: Procedure codes: 44188, 44206, 44320, 45355, 44970, 58558, Claims with the following DRG codes are excluded based on the CMS exclusions for Colonoscopy: MS-DRG codes: 0001, 0002, 0007, 0011, 0012, 0013, 0014, 0016, 0017, 0020, 0021, 0022, 0023, 0024, 0025, 0026, 0027, 0028, 0029, 0030, 0031, 0032, 0033, 0034, 0035, 0036, 0037, 0038, 0039, 0040, 0041, 0042, 0113, 0114, 0115, 0116, 0117, 0129, 0130, 0131, 0132, 0133, 0134, 0135, 0136, 0137, 0138, 0139, 0163, 0164, 0165, 0216, 0217, 0218, 0219, 0220, 0221, 0222, 0223, 0224, 0225, 0226, 0227, 0228, 0229, 0230, 0231, 0232, 0233, 0234, 0235, 0236, 0237, 0238, 0239, 0240, 0241, 0242, 0243, 0244, 0245, 0246, 0247, 0248, 0249, 0250, 0251, 0252, 0253, 0254, 0255, 0256, 0257, 0258, 0259, 0260, 0261, 0262, 0263, 0264, 0265, 0335, 0336, 0337, 0338, 0339, 0340, 0341, 0342, 0343, 0350, 0351, 0352, 0353, 0354, 0355, 0411, 0412, 0413, 0414, 0415, 0416, 0417, 0418, 0419, 0453, 0454, 0455, 0456, 0457, 0458, 0459, 0460, 0461, 0462, 0463, 0464, 0465, 0466, 0467, 0468, 0469, 0470, 0471, 0472, 0473, 0474, 0475, 0476, 0477, 0478, 0479, 0480, 0481, 0482, 0483, 0484, 0485, 0486, 0487, 0488, 0489, 0490, 0491, 0492, 0493, 0494, 0495, 0496, 0497, 0498, 0499, 0500, 0501, 0502, 0503, 0504, 0505, 0506, 0507, 0508, 0509, 0510, 0511, 0512, 0513, 0514, 0515, 0516, 0517, 0570, 0571, 0572, 0573, 0574, 0575, 0576, 0577, 0578, 0579, 0580, 0581, 0582, 0583, 0584, 0585, 0614, 0615, 0619, 0620, 0621, 0625, 0626, 0627, 0628, 0629, 0630, 0652, 0653, 0654, 0655, 0656, 0657, 0658, 0659, 0660, 0661, 0662, 0663, 0664, 0665, 0666, 0667, 0668, 0669, 0670, 0671, 0672, 0673, 0674, 0675, 0707, 0708, 0709, 0710, 0711, 0712, 0713, 0714, 0715, 0716, 0717, 0718, 0734, 0735, 0736, 0737, 0738, 0739, 0740, 0741, 0742, 0743, 0744, 0745, 0746, 0747, 0748, 0749, 0750, 0765, 0766, 0767, 0768, 0769, 0770, 0799, 0800, 0801, 0820, 0821, 0822, 0823, 0824, 0825, 0826, 0827, 0828, 0829, 0830, 0856, 0857, 0858, 0876, 0901, 0902, 0903, 0904, 0905, 0906, 0907, 0908, 0909, 0927, 0928, 0929, 0955, 0956, 0957, 0958, 0959, 0969, 0970, 0984, 0985, 0986 Please see the final pages of this document for a list of the corresponding ICD-10 codes

10 Colonoscopy Algorithm Summary v1.6 Page 8 of 18 Claims Included Claims with one of the following codes within the episode window will be included in the episode. codes ICD-9 Diagnosis: , , 003.9, 004.0, 004.1, 004.2, 004.3, 004.8, 004.9, 005.0, 005.1, 005.2, 005.3, 005.4, 005.8, , , 005.9, 006.0, 006.1, 006.2, 006.6, 006.8, 006.9, 007.0, 007.1, 007.2, 007.3, 007.5, 007.8, 007.9, 008.0, , , , , , , 008.1, 008.2, 008.3, , , , , , , , , 008.5, 008.6, , , , , , , , , 008.8, 009.0, 009.1, 009.2, 009.3, 021.1, 022.2, 153.0, 153.1, 153.2, 153.3, 153.4, 153.5, 153.6, 153.7, 153.8, 153.9, 154.0, 154.1, 154.2, 154.3, 154.8, 159.0, 159.8, 159.9, 176.3, 176.5, 176.8, 176.9, 194.8, 194.9, 195.2, 195.3, 195.8, 196.2, 196.6, 196.8, 196.9, 197.5, 197.6, 197.7, 197.8, , 199.0, 199.1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 211.3, 211.4, 230.3, 230.4, 230.5, 230.6, 230.7, 230.9, 234.8, 234.9, 235.2, 235.4, 235.5, 237.4, 237.7, , , , , , 237.9, 238.8, 238.9, 239.0, 239.8, , 239.9, 280.0, 280.1, 280.8, 280.9, 285.0, , , , 285.3, 285.8, 285.9, 455.0, 455.1, 455.2, 455.3, 455.4, 455.5, 455.6, 455.7, 455.8, 455.9, 538, 555.0, 555.1, 555.2, 555.9, 556, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 557.0, 557.1, 557.9, 558.1, 558.2, 558.3, , , 558.9, 560.0, 560.1, 560.2, 560.9, , , , , , , , , 564.0, , , , , 564.1, 564.2, 564.5, 564.6, 564.7, 564.8, , , 564.9, 565.0, 565.1, 566, 568.0, , , 568.9, 569.0, 569.1, 569.2, 569.3, , , , , , , , , , , , , 569.9, 578.1, 578.9, 579.0, 579.1, 579.2, 579.8, 579.9, 751.0, 751.1, 751.2, 751.3, 751.4, 751.5, 751.8, 751.9, 787.1, 787.2, , , , , , , 787.3, 787.4, 787.5, 787.6, , , , , 787.7, 787.9, , , 789.0, , , , , , , , , 789.3, , , , , , , , , , 789.4, , , , , , , , , , , , , , , , , , , , 789.9, 792.1, 793.4, 793.6, , , , , , , V10.00, V10.05, V10.06, V10.09, V10.89, V10.9, V10.90, V10.91, V12.7, V12.70, V12.72, V12.79, V13.67, V16.0, V18.51, V44.1, V44.2, V44.3, V44.4, V45.3, V47.3, V53.5, V53.50, V53.51, V53.59, V55.1, V55.2, V55.3, V55.4, V71.1, V76.41, V76.49, V76.50, V76.51 ICD-9 Procedure: 45.23, 45.24, 45.25, 45.27, ICD-10 Procedure: 0D9E3ZX, 0D9E4ZX, 0D9E7ZX, 0D9E8ZX, 0D9F3ZX, 0D9F4ZX, 0D9F7ZX, 0D9F8ZX, 0D9G3ZX, 0D9G4ZX, 0D9G7ZX, 0D9G8ZX, 0D9H3ZX, 0D9H4ZX, 0D9H7ZX, 0D9H8ZX, 0D9K3ZX, 0D9K4ZX, 0D9K7ZX, 0D9K8ZX, 0D9L3ZX, 0D9L4ZX, 0D9L7ZX, 0D9L8ZX, 0D9M3ZX, 0D9M4ZX, 0D9M7ZX, 0D9M8ZX, 0D9N3ZX, 0D9N4ZX, 0D9N7ZX, 0D9N8ZX, 0DBE3ZX, 0DBE4ZX, 0DBE7ZX, 0DBE8ZX, 0DBE8ZZ, 0DBF3ZX, 0DBF4ZX, 0DBF7ZX, 0DBF8ZX, 0DBF8ZZ, 0DBG3ZX, 0DBG4ZX, 0DBG7ZX, 0DBG8ZX, 0DBG8ZZ, 0DBH3ZX, 0DBH4ZX, 0DBH7ZX, 0DBH8ZX, 0DBH8ZZ, 0DBK3ZX, 0DBK4ZX, 0DBK7ZX, 0DBK8ZX, 0DBK8ZZ, 0DBL3ZX, 0DBL4ZX, 0DBL7ZX, 0DBL8ZX, 0DBL8ZZ, 0DBM3ZX, 0DBM4ZX, 0DBM7ZX, 0DBM8ZX, 0DBM8ZZ, 0DBN3ZX, 0DBN4ZX, 0DBN7ZX, 0DBN8ZX, 0DBN8ZZ, 0DJD8ZZ, I83201, I83202, I83203, I83204, I83205, I83208, I83209, I83211, I83212, I83213, I83214, I83215, I83218, I83219, I83221, I83222, I83223, I83224, I83225, I83228, I83229 CPT: 44388, 44389, 44390, 44391, 44392, 44393, 44394, 44397, 45300, 45303, 45305, 45307, 45308, 45309, 45315, 45317, 45320, 45321, 45327, 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45339, 45340, 45341, 45342, 45345, 45355, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45386, 45387, 45391, 45392, 74150, 74160, 74170, 74181, 74182, 74183, 74185, 76700, 76705, 76975, 91111, 96570, 96571, G0104, G0105, G0121

11 Colonoscopy Algorithm Summary v1.6 Page 9 of 18 Claims included codes (continued) NDC: There are more than 50,000 NDC codes, can provide upon request. In addition to the codes listed above for both pre and post-procedure window, there are additional codes that are only captured in postprocedure window. ICD-9 codes: 003.1, 007.4, 031.0, 031.2, 036.2, 038.0, , , , 038.2, 038.3, , , , , , , 038.8, 038.9, , , , 054.5, 073.0, 078.5, 083.0, 112.4, 112.5, 114.0, 114.4, 114.5, 117.3, 117.5, 117.7, 118, 130.0, 130.4, ICD-10 codes: 8E09XBG, 8E0WXBG, 8E0XXBG, 8E0YXBG, A021, A072, A310, A312, A392, A393, A394, A400, A401, A403, A408, A409, A4101, A411, A412, A413, A414, A4150, A4151, A4152, A4153, A4159, A4181, A4189, A419, A427, A483, A4852, A4902, A78, B007, B250, B251, B252, B258, B259, B371, B377, B380, B381, B382, B450, B451, B452, B453, B457, B458, B459, B460, B461, B462, B463, B464, B465, B468, B469, B488, B582, B583, B9562

12 Colonoscopy Algorithm Summary v1.6 Page 10 of 18 Claims included Claims with one of the following codes within the episode window will be included in the episode. codes (continued) ICD-9 codes (continued): 130.8, 136.3, , , , , , , , , , , , , 251.0, 276.0, 276.1, 276.2,276.3, 276.4, 276.5, , , , 276.6, , , 276.7, 276.8, 276.9, 286.6, 287.4, , , 293.0, 293.1, , , , , , , , , , , , 339.3, , 348.1, , , , 348.4, 348.5, , , 381.2, 401.0, , 417.8, 417.9, 427.0, 427.1, 427.2, , , , , 427.5, 427.8, , 427.9, 437.2, 451.0, , , 451.2, , , , , , 451.9, 453.1, 453.2, 453.3, , , , , , , 453.6, , 453.8, 453.9, 456.5, 456.6, 456.8, 457.1, 457.2, 457.8, 457.9, 458.0, 458.1, 458.2, , 458.8, 458.9, 459.0, 459.1, , , , , 459.2, 511.0, 511.1, 511.8, , 511.9, 517.3, 518.0, 518.7, , , , , , , , , , , , , , , , 567.0, 567.1, 567.2, , , , , , , , 567.8, , , 567.9, , 569.5, 569.6, , , , , , , , 579.3, 614.5, , , 780.0, , , , 780.2, 780.4, 780.6, , , , , , , 785.0, 785.1, , , , , , , , , , , 790.7, , 799.0, , , 799.1, , , , , , , 909.0, 909.3, 909.5, 960.0, 960.1, 960.2, 960.3, 960.4, 960.5, 960.6, 960.7, 960.8, 960.9, 961.0, 961.1, 961.2, 961.3, 961.4, 961.5, 961.6, 961.7, 961.8, 961.9, 962.0, 962.1, 962.2, 962.3, 962.4, 962.5, 962.6, 962.7, 962.8, 962.9, 963.0, 963.1, 963.2, 963.3, 963.4, 963.5, 963.8, 963.9, 964.0, 964.1, 964.2, 964.3, 964.4, 964.5, 964.6, 964.7, 964.8, 964.9, , 965.1, 965.4, 965.5, 965.6, , , 965.7, 965.8, 965.9, 966.0, 966.1, 966.2, 966.3, 966.4, 967.0, 967.1, 967.2, 967.3, 967.4, 967.5, 967.6, 967.8, 967.9,968.0, 968.1, 968.2, 968.3, 968.4, 968.5, 968.6, 968.7, 968.9, 969.0, , , , , , , , 969.1, 969.2, 969.3, 969.4, 969.5, 969.8, 969.9, 970.0, 970.1, 970.8, 970.9, 971.0, 971.1, 971.2, 971.3, 971.9, 972.0, 972.1, 972.2, 972.3, 972.4, 972.5, 972.6, 972.7, 972.8, 972.9, 973.0, 973.1, 973.2, 973.3, 973.4, 973.5, 973.6, 973.8, 973.9, 974.0, 974.1, 974.2, 974.3, 974.4, 974.5, 974.6, 974.7, 975.0, 975.1, 975.2, 975.3, 975.4, 975.5, 975.6, 975.7, 975.8, 976.0, 976.1, 976.2, 976.3, 976.4, 976.5, 976.6, 976.7, 976.8, 976.9, 977.0, 977.1, 977.2, 977.3, 977.4, 977.8, 977.9, 978.0, 978.1, 978.2, 978.3, 978.4, 978.5, 978.6, 978.8, 978.9, 979.0, 979.1, 979.2, 979.3, 979.4, 979.5, 979.6, 979.7, 979.9, 995.0, , , , , , , , 995.3, 995.4, , , , , , 996.6, , , 996.7, , , , , 997.3, , , 997.4, 997.5, , 997.9, , , 998.0, 998.1, , , , 998.2, 998.3, , , , 998.4, 998.5, , , 998.6, 998.7, 998.8, , , , 998.9, 999.0, 999.1, 999.2, 999.3, , , 999.4, 999.5, 999.6, , , , , , 999.7, , , , , , , , , , , 999.8, , , , , , , , , 999.9, E85.02, E85.03, E85.04, E85.05, E85.06, E85.07, E85.08, E85.09, E85.1, E85.20, E85.21, E85.22, E85.23, E85.24, E85.25, E85.28, E85.29, E85.30, E85.31, E85.32, E85.38, E85.39, E85.40, E85.43, E85.48, E85.50, E85.51, E85.52, E85.53, E85.54, E85.55, E85.56, E85.58, E85.59, E85.6, E85.7, E85.80, E85.81, E85.82, E85.83, E85.84, E85.85, E85.86, E85.87, E85.88, E85.89, E87.00, E87.01, E87.02, E87.03, E87.04, E87.07, E87.08, E87.09, E87.10, E87.11, E87.12, E87.13, E87.14, E87.15, E87.18, E87.19, E87.20, E87.21, E87.22, E87.23, E87.24, E87.25, E87.28, E87.29, E87.30, E87.31, E87.34, E87.35, E87.36, E87.38, E87.39, E87.40, E87.41, E87.42, E87.43, E87.44, E87.48, E87.49, E87.50, E87.51, E87.52, E87.58, E87.59, E87.60, E87.61, E87.62, E87.63, E87.64, E87.65, E87.66, E87.68, E87.69, E87.83, E87.88, E87.89, E87.93, E87.94, E87.95, E87.96, E87.97, E87.98, E87.99, E93.00, E93.01, E93.02, E93.03, E93.04, E93.05, E93.06, E93.07, E93.08, E93.09, E93.10, E93.11, E93.12, E93.13, E93.14, E93.15, E93.16, E93.17, E93.18, E93.19, E93.20, E93.30,

13 Colonoscopy Algorithm Summary v1.6 Page 11 of 18 Claims included codes (continued) Claims with one of the following codes within the episode post-procedure window will be included in the episode. ICD-9 codes (continued): E93.32, E93.33, E93.34, E93.35, E93.36, E93.37, E93.38, E93.39, E93.40, E93.41, E93.42, E93.43, E93.44, E93.45, E93.46, E93.47, E93.48, E93.49, E93.52, E93.53, E93.54, E93.55, E93.56, E93.57, E93.58, E93.59, E93.60, E93.61, E93.62, E93.63, E93.64, E93.70, E93.71, E93.72, E93.73, E93.74, E93.75, E93.76, E93.78, E93.79, E93.80, E93.81, E93.82, E93.83, E93.84, E93.85, E93.86, E93.87, E93.89, E93.90, E93.91, E93.92, E93.93, E93.94, E93.95, E93.96, E93.97, E93.98, E93.99, E94.00, E94.01, E94.08, E94.09, E94.10, E94.11, E94.12, E94.13, E94.19, E94.20, E94.21, E94.22, E94.23, E94.24, E94.25, E94.26, E94.27, E94.28, E94.29, E94.30, E94.31, E94.32, E94.33, E94.34, E94.35, E94.36, E94.38, E94.39, E94.40, E94.41, E94.42, E94.43, E94.44, E94.45, E94.46, E94.47, E94.50, E94.51, E94.52, E94.53, E94.54, E94.55, E94.56, E94.57, E94.58, E94.60, E94.61, E94.62, E94.63, E94.64, E94.65, E94.66, E94.67, E94.68, E94.69, E94.70, E94.71, E94.72, E94.73, E94.74, E94.78, E94.79, E94.99, E97.2, E98.00, E98.01, E98.02, E98.03, E98.04, E98.05, V09.0, V09.1, V09.2, V09.3, V09.4, V09.50, V09.51, ICD-9 codes (continued): V09.6, V09.70, V09.71, V09.80, V09.81, V09.90, V09.91, V15.53, V15.80, V46.1, V46.11, V46.12, V46.13, V46.14, V46.2 NDC: There are more than 11,000 NDC codes, can provide upon request. Quality codes Please see the final pages of this document for a list of the corresponding ICD-10 codes Quality measures to track (not payment related): Perforation rate calculated based on diagnosis codes with the same date as the trigger procedure date ICD-9 Diagnosis: Post polypectomy/biopsy bleed rate based on diagnoses on any claim during the episode window ICD-9 Diagnosis: , , , , , , Please see the final pages of this document for a list of the corresponding ICD-10 codes

14 Colonoscopy Algorithm Summary v1.6 Page 12 of 18 Exclusion Patients who have co-morbid condition(s) indicated by the following ICD-9-CM codes will be excluded: codes ICD-10-CM codes: A4851, C153, C154, C155, C158, C159, C160, C164, C163, C161, C162, C165, C166, C168, C169, C170, C171, C172, C173, C178, C179, C183, C184, C186, C187, C180, C181, C182, C185, C188, C189, C19, C20, C211, C210, C212, C218, C220, C222, C223, C224, C227, C228, C221, C229, C23, C240, C241, C248, C249, C250, C251, C252, C253, C254, C257, C258, C259, C480, C451, C481, C488, C482, C260, C261, C269, C33, C3400, C3401, C3402, C3410, C3411, C3412, C342, C3430, C3431, C3432, C3480, C3481, C3482, C3490, C3491, C3492, C384, C450, C37, C380, C452, C381, C382, C388, C383, C390, C399, C410, C411, C412, C413, C4000, C4001, C4002, C4010, C4011, C4012, C414, C4020, C4021, C4022, C4030, C4031, C4032, C4080, C4081, C4082, C4090, C4091, C4092, C419, C470, C490, C4710, C4711, C4712, C4910, C4911, C4912, C4720, C4721, C4722, C4920, C4921, C4922, C473, C493, C474, C494, C475, C495, C476, C496, C478, C498, C479, C499, C460, C461, C462, C464, C4650, C4651, C4652, C463, C467, C469, C58, C561, C562, C569, C5700, C5701, C5702, C5710, C5711, C5712, C573, C5720, C5721, C5722, C574, C574, C52, C510, C511, C512, C519, C518, C577, C578, C579, C600, C601, C602, C609, C6300, C6301, C6302, C6310, C6311, C6312, C632, C608, C637, C638, C639, C641, C642, C649, C651, C652, C659, C661, C662, C669, C680, C681, C688, C689, C6940, C6941, C6942, C6960, C6961, C6962, C6900, C6901, C6902, C6910, C6911, C6912, C6920, C6921, C6922, C6930, C6931, C6932, C6950, C6951, C6952, C6980, C6981, C6982, C6990, C6991, C6992, C710, C711, C712, C713, C714, C715, C716, C717, C718, C719, C7220, C7221, C7222, C7230, C7231, C7232, C7240, C7241, C7242, C7250, C7259, C700, C709, C720, C721, C701, C729, C7400, C7401, C7402, C7410, C7411, C7412, C7490, C7491, C7492, C750, C751, C752, C753, C754, C755, C758, C759, C761, C762, C763, C7640, C7641, C7642, C7650, C7651, C7652, C457, C768, C770, C771, C772, C773, C774, C775, C778, C779, C7800, C7801, C7802, C781, C782, C7830, C7839, C784, C785, C786, C787, C7880, C7889, C7900, C7901, C7902, C7910, C7911, C7919, C792, C7931, C7932, C7940, C7949, C7951, C7952, C7960, C7961, C7962, C7970, C7971, C7972, C7981, C7982, C7989, C799, C800, C459, C801, C802, C96A, C960, C962, C7A019, C7A010, C7A011, C7A012, C7A029, C7A020, C7A021, C7A022, C7A023, C7A024, C7A025, C7A026, C7A00, C7A090, C7A091, C7A092, C7A093, C7A094, C7A095, C7A096, C7A098, C7A1, C7A8, C7B00, C7B01, C7B02, C7B03, C7B04, C7B1, C7B09, C7B8, D001, D002, D010, D011, D012, D013, D0140, D0149, D015, D017, D019, D021, D0220, D0221, D0222, D023, D024, D0730, D072, D071, D0739, D074, D0760, D0761, D0769, D0910, D0919, D0920, D0921, D0922, D093, D098, D099, D37030, D37031, D37032, D37039, D3701, D3702, D3704, D3705, D3709, D371, D372, D373, D374, D375, D376, D483, D484, D378, D379, D380, D381, D382, D383, D384, D385, D386, D390, D392, D3910, D3911, D3912, D398, D399, D4010, D4011, D4012, D400, D408, D409, D414, D419, D4100, D4101, D4102, D4110, D4111, D4112, D4120, D4121, D4122, D413, D418, D443, D444, D445, D4410, D4411, D4412, D446, D447, D440, D442, D449, D430, D431, D432, D434, D420, D421, D429, Q8500, Q8501, Q8502, Q8503, Q8509, D433, D438, D439, D480, D481, D482, D485, D4860, D4861, D4862, D45, D470, D473, D460, D461, D4620, D4621, D464, D46A, D46B, D4622, D46C, D469, D46Z, D47Z1, C888, C9440, C9441, C9442, C946, D471, D479, D47Z9, D487, D489, D490, D491, D492, D493, D494, D495, D496, D497, D4981, D4989, D499, I7300, I7301, I7772, J910, K5000, K50011, K50012, K50013, K50014, K50018, K50019, K5010, K50111, K50112, K50113, K50114, K50118, K50119, K5080, K50811, K50812, K50813, K50814, K50818, K50819, K5090, K50911, K50912, K50913, K50914, K50918, K50919, K5120, K51211, K51212, K51213, K51214, K51218, K51219, K5130, K51311, K51312, K51313, K51314, K51318, K51319, K5140, K51411, K51412, K51413, K51414, K51418, K51419, K5150, K51511, K51512, K51513, K51514, K51518, K51519, K5100, K51011, K51012, K51013, K51014, K51018, K51019, K5180, K51811, K51812, K51813, K51814, K51818, K51819, K5190, K51911, K51912, K51913, K51914, K51918, K51919, N185, N186, O010, O011, O019, O0281, O020, O0289, O029, O021, O000, O001, O002, O008, O009, O030, O0337, O035, O0387, O031, O036, O0334, O0384, O0332, O0382, O0333, O0383, O0331, O0381, O037, O032, O0335, O0336, O0338, O0339, O0385, O0386, O0388, O0389, O0330, O0380, O034, O039, O045, O0487, O046, O0484, O0482, O0483, O0481, O047, O0485, O0486, O0488, O0489, O0480, Z332, O070, O0737, O071, O0734, O0732,

15 Colonoscopy Algorithm Summary v1.6 Page 13 of 18 Exclusion ICD-10-CM codes: O0733, O0731, O072, O0735, O0736, O0738, O0739, O0730, O074, A34, O080, O0882, O081, O086, O084, O085, O083, codes O082, O087, O0881, O0883, O0889, O089, O200, O208, O209, O4400, O4401, O4402, O4403, O4410, O4411, O4412, O4413, O458X9, (continued) O4590, O458X1, O458X2, O458X3, O4591, O4592, O4593, O45009, O45019, O45029, O45099, O46009, O46019, O46029, O46099, O45001, O45002, O45003, O45011, O45012, O45013, O45021, O45022, O45023, O45091, O45092, O45093, O46001, O46002, O46003, O46011, O46012, O46013, O46021, O46022, O46023, O46091, O46092, O46093, O670, O468X9, O468X1, O468X2, O468X3, O678, O4690, O4691, O4692, O4693, O679, O10019, O10919, O10011, O10012, O10013, O1002, O10911, O10912, O10913, O1092, O1003, O1093, O10419, O10411, O10412, O10413, O1042, O1043, O10119, O10219, O10319, O10111, O10112, O10113, O1012, O10211, O10212, O10213, O1022, O10311, O10312, O10313, O1032, O1013, O1023, O1033, O139, O131, O132, O133, O161, O162, O163, O1400, O1490, O1402, O1403, O1492, O1493, O152, O1410, O1420, O1412, O1413, O1422, O1423, O1500, O159, O1502, O1503, O151, O152, O119, O111, O112, O113, O169, O161, O169, O210, O211, O212, O218, O219, O219, O6000, O6002, O6003, O4700, O479, O4702, O4703, O471, O6010X0, O6010X1, O6010X2, O6010X3, O6010X4, O6010X5, O6010X9, O6020X0, O6020X1, O6020X2, O6020X3, O6020X4, O6020X5, O6020X9, O6012X0, O6012X1, O6012X2, O6012X3, O6012X4, O6012X5, O6012X9, O6013X0, O6013X1, O6013X2, O6013X3, O6013X4, O6013X5, O6013X9, O6014X0, O6014X1, O6014X2, O6014X3, O6014X4, O6014X5, O6014X9, O6022X0, O6022X1, O6022X2, O6022X3, O6022X4, O6022X5, O6022X9, O6023X0, O6023X1, O6023X2, O6023X3, O6023X4, O6023X5, O6023X9, O480, O481, O3100X0, O3100X1, O3100X2, O3100X3, O3100X4, O3100X5, O3100X9, O3101X0, O3101X1, O3101X2, O3101X3, O3101X4, O3101X5, O3101X9, O3102X0, O3102X1, O3102X2, O3102X3, O3102X4, O3102X5, O3102X9, O3103X0, O3103X1, O3103X2, O3103X3, O3103X4, O3103X5, O3103X9, O1200, O1220, O2600, O1201, O1202, O1203, O1221, O1222, O1223, O2601, O2602, O2603, O1210, O1220, O26839, O1221, O1222, O1223, O1211, O1212, O1213, O26831, O26832, O26833, O2620, O2621, O2622, O2623, O26829, O26821, O26822, O26823, O2300, O2310, O2320, O2330, O2340, O23519, O23529, O23599, O2390, O2301, O2302, O2303, O2311, O2312, O2313, O2321, O2322, O2323, O2331, O2332, O2333, O2341, O2342, O2343, O23511, O23512, O23513, O23521, O23522, O23523, O23591, O23592, O23593, O2391, O2392, O2393, O8611, O8613, O8619, O8620, O8621, O8622, O8629, O26619, O26611, O26612, O26613, O2662, O2610, O2630, O2640, O26719, O26819, O26899, O29019, O29029, O29099, O29119, O29129, O29199, O29219, O29299, O293X9, O2940, O295X9, O2960, O298X9, O2990, O99350, O2611, O2612, O2613, O2631, O2632, O2633, O2641, O2642, O2643, O26711, O26712, O26713, O2672, O26811, O26812, O26813, O2686, O26891, O26892, O26893, O2691, O2692, O2693, O29011, O29012, O29013, O29021, O29022, O29023, O29091, O29092, O29093, O29111, O29112, O29113, O29121, O29122, O29123, O29191, O29192, O29193, O29211, O29212, O29213, O29291, O29292, O29293, O293X1, O293X2, O293X3, O2941, O2942, O2943, O295X1, O295X2, O295X3, O2961, O2962, O2963, O298X1, O298X2, O298X3, O2991, O2992, O2993, O99351, O99352, O99353, O99354, O9989, O99355, O9989, O2663, O2673, O2690, O98119, O98111, O98112, O98113, O9812, O9813, O98219, O98211, O98212, O98213, O9822, O9823, O98319, O98311, O98312, O98313, O9832, O9833, O98019, O98011, O98012, O98013, O9802, O9803, O98619, O9862, O9863, O98419, O98519, O98719, O98411, O98412, O98413, O9842, O98511, O98512, O98513, O9852, O98711, O98712, O98713, O9872, O9843, O9853, O9873, O98819, O98611, O98612, O98613, O98811, O98812, O98813, O9882, O99830, O99834, O9883, O99835, O98919, O98911, O98912, O98913, O9892, O9893, O24019, O24119, O24319, O24819, O24919, O24011, O24012, O24013, O2402, O24111, O24112, O24113, O2412, O24311, O24312, O24313, O2432, O24811, O24812, O24813, O2482, O24911, O24912, O24913, O2492, O2493, O2403, O2413, O2433, O2483, O2493, O905, O99019, O99011, O99012, O99013, O9902, O9903, O9081, O99320, O99321, O99322, O99323, O99324, O99325, O99310, O99340, O99311, O99312, O99313, O99314, O99341, O99342, O99343, O99344, O906, O99315, O99345, O99419, O9943, O330, O24410, O24414, O24419, O24420, O24424, O24429, O99810, O99814, O24430, O24434, O24439, O99815, O2510, O99280, O99519, O99619, O99719, O9A119, O9A219, O9A319,

16 Colonoscopy Algorithm Summary v1.6 Page 14 of 18 Exclusion ICD-10-CM codes: O9A419, O9A519, O2511, O2512, O2513, O252, O99281, O99282, O99283, O99284, O99511, O99512, O99513, O9952, codes O99611, O99612, O99613, O9962, O99711, O99712, O99713, O9972, O99824, O9A111, O9A112, O9A113, O9A12, O9A211, O9A212, (continued) O9A213, O9A22, O9A311, O9A312, O9A313, O9A32, O9A411, O9A412, O9A413, O9A42, O9A511, O9A512, O9A513, O9A52, O99285, O99820, O253, O9953, O9963, O9973, O99825, O9A13, O9A23, O9A33, O9A43, O9A53, O99330, O99331, O99332, O99333, O99334, O99335, O99210, O99211, O99212, O99213, O99214, O99215, O99840, O99841, O99842, O99843, O99844, O99845, O99119, O99111, O99112, O99113, O9912, O9913, O9913, O26859, O26851, O26852, O26853, O26849, O26841, O26842, O26843, O26879, O26872, O26873, O7582, O80, O30009, O30019, O30039, O30049, O30099, O30001, O30002, O30003, O30011, O30012, O30013, O30031, O30032, O30033, O30041, O30042, O30043, O30091, O30092, O30093, O30109, O30101, O30102, O30103, O30111, O30112, O30113, O30121, O30122, O30123, O30191, O30192, O30193, O30209, O30211, O30212, O30213, O30221, O30222, O30223, O30291, O30292, O30293, O30201, O30202, O30203, O3110X0, O3110X1, O3110X2, O3120X0, O3120X1, O3120X2, O3111X0, O3111X1, O3111X2, O3112X0, O3112X1, O3112X2, O3113X0, O3113X1, O3113X2, O3121X0, O3121X1, O3121X2, O3122X0, O3122X1, O3122X2, O3123X0, O3123X1, O3123X2, O3110X3, O3110X4, O3110X5, O3110X9, O3120X3, O3120X4, O3120X5, O3120X9, O3111X3, O3111X4, O3111X5, O3111X9, O3112X3, O3112X4, O3112X5, O3112X9, O3113X3, O3113X4, O3113X5, O3113X9, O3121X3, O3121X4, O3121X5, O3121X9, O3122X3, O3122X4, O3122X5, O3122X9, O3123X3, O3123X4, O3123X5, O3123X9, O3130X0, O3130X1, O3130X2, O3130X3, O3130X4, O3130X5, O3130X9, O3131X0, O3131X1, O3131X2, O3131X3, O3131X4, O3131X5, O3131X9, O3132X0, O3132X1, O3132X2, O3132X3, O3132X4, O3132X5, O3132X9, O3133X0, O3133X1, O3133X2, O3133X3, O3133X4, O3133X5, O3133X9, O30809, O30811, O30812, O30813, O30821, O30822, O30823, O30891, O30892, O30893, O30801, O30802, O30803, O318X10, O318X11, O318X12, O318X13, O318X14, O318X15, O318X19, O318X20, O318X21, O318X22, O318X23, O318X24, O318X25, O318X29, O318X30, O318X31, O318X32, O318X33, O318X34, O318X35, O318X39, O3090, O318X90, O318X91, O318X92, O318X93, O318X94, O318X95, O318X99, O3091, O3092, O3093, O320XX0, O320XX1, O320XX2, O320XX3, O320XX4, O320XX5, O320XX9, O321XX0, O321XX1, O321XX2, O321XX3, O321XX4, O321XX5, O321XX9, O641XX0, O641XX1, O641XX2, O641XX3, O641XX4, O641XX5, O641XX9, O322XX0, O322XX1, O322XX2, O322XX3, O322XX4, O322XX5, O322XX9, O323XX0, O323XX1, O323XX2, O323XX3, O323XX4, O323XX5, O323XX9, O642XX0, O642XX1, O642XX2, O642XX3, O642XX4, O642XX5, O642XX9, O643XX0, O643XX1, O643XX2, O643XX3, O643XX4, O643XX5, O643XX9, O324XX0, O324XX1, O324XX2, O324XX3, O324XX4, O324XX5, O324XX9, O329XX0, O329XX1, O329XX2, O329XX3, O329XX4, O329XX5, O329XX9, O666, O326XX0, O326XX1, O326XX2, O326XX3, O326XX4, O326XX5, O326XX9, O328XX0, O328XX1, O328XX2, O328XX3, O328XX4, O328XX5, O328XX9, O644XX0, O644XX1, O644XX2, O644XX3, O644XX4, O644XX5, O644XX9, O645XX0, O645XX1, O645XX2, O645XX3, O645XX4, O645XX5, O645XX9, O648XX0, O648XX1, O648XX2, O648XX3, O648XX4, O648XX5, O648XX9, O649XX0, O649XX1, O649XX2, O649XX3, O649XX4, O649XX5, O649XX9, O650, O331, O651, O332, O652, O333XX0, O333XX1, O333XX2, O333XX3, O333XX4, O333XX5, O333XX9, O653, O334XX0, O334XX1, O334XX2, O334XX3, O334XX4, O334XX5, O334XX9, O654, O335XX0, O335XX1, O335XX2, O335XX3, O335XX4, O335XX5, O335XX9, O662, O336XX0, O336XX1, O336XX2, O336XX3, O336XX4, O336XX5, O336XX9, O337, O338, O339, O3400, O3401, O3402, O3403, O3410, O3411, O3412, O3413, O3421, O34519, O34539, O34511, O34512, O34513, O34531, O34532, O34533, O34529, O34599, O34521, O34522, O34523, O34591, O34592, O34593, O3430, O3431, O3432, O3433, O3440, O3441, O3442, O3443, O3460, O3461, O3462, O3463, O3470, O3471, O3472, O3473, O3480, O3490, O3429, O3481, O3482, O3483, O3491, O3492, O3493, O658, O659, O350XX0, O350XX1, O350XX2, O350XX3, O350XX4, O350XX5, O350XX9, O351XX0, O351XX1, O351XX2, O351XX3, O351XX4, O351XX5, O351XX9, O352XX0, O352XX1, O352XX2, O352XX3, O352XX4, O352XX5, O352XX9, O353XX0, O353XX1, O353XX2, O353XX3, O353XX4, O353XX5, O353XX9, O354XX0, O354XX1, O354XX2, O354XX3, O354XX4, O354XX5, O354XX9, O355XX0, O355XX1, O355XX2, O355XX3,