Form #1 Form #1 Electronic patient record review

								Form Approved OMB No. 0935-XXXX Exp. Date XX/XX/20XX
Electronic Records Review Programming Guide
Eligibility Criteria
1	Age 50-79
2	Visit to practice within 2 years
3	Complete mailing address (first and last name, street address, city, state, zip code)
4	No DX of CRC or polyps or inflammatory bowel disease
		(see Table 1 - List of Excluded DX Codes)
5	No family HX of CRC diagnoses before age 60
6	No recent CRC tests (see Table 2 - List of Excluded Procedure Codes)
		SBT within 1 year
		Sig within 5 years
		BE within 5 years
		CX within 10 years
Table 1. List of ICD9 Codes for Excluded Diagnoses
	Diagnosis				ICD9 Codes
	Malignant neoplasms				153.0 – 154.8
	Benign neoplasms				211.3 – 211.4
	Colorectal and Intestinal neoplasms				159
					197.5, 197.8
					211.9
					230.3 – 230.4, 230.7
					235.2, 239.0
	Regional enteritis (Crohn’s disease)				555.0 – 555.9
	Ulcerative colitis				556.0 – 556.9
	History of colon polyps				V12.72
Table 2 - List of Excluded Procedure Codes
	Procedure		CPT Codes		HCPCS Codes		ICD9 Codes
	Stool Blood Test		82270, 82274		G0107, G0328		V76.51
	Sigmoidoscopy		45330-45335,		G0104		45.24, 45.42
			45337-45342,
			45345
	Barium Enema		74270, 74280		G0106, G0120,
					G0122
	Colonoscopy		44388-44394,		G0105, G0121		45.22, 45.23,
			44397, 45355,				45.25, 45.43
			45378-45387,
			45391, 45392
Public reporting burden for this collection of information is estimated to average 5.66 hours per response, the estimated time required to complete the review. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Form Approved: OMB Number 0935-XXXX Exp. Date xx/xx/20xx. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.