CMS 166v7: Use of Imaging Studies for Low Back Pain

Measure: Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis

This measure is for use in the Medicaid EHR Incentive Program for Eligible Professionals only

Measure Type High Priority Measure Scoring
Process Yes A higher percentage indicates better quality
Denominator Patients 18-50 years of age with a diagnosis of uncomplicated low back pain during a visit
Numerator Patients without an imaging study conducted on the index episode start date or in the 28 days following the index episode start date
Denominator Exceptions None
Denominator Exclusions

Exclude patients:

  • With a diagnosis of uncomplicated low back pain during the 180 days (6 months) prior to the index episode start date
  • With neurologic impairment, spinal infection, or diagnosis of IV drug abuse any time during the 12 months prior to the index episode start date through 28 days after the index episode start date
  • With trauma any time during the 90 days prior to the index episode start date through 28 days after the index episode start date
  • With a diagnosis of HIV or cancer any time in the patient's history through 28 days after the index episode start date
  • Who had a major organ transplant any time in the patient's history through 28 days after the index episode start date
  • Who had prolonged use of corticosteroids (at least 90 consecutive days) any time in the 12 months prior to the index episode start date
  • Who were in hospice care during the measurement year

Patients who meet the following criteria will be included in the denominator:

  • Age must be ≥ 18 years and < 50 years at the beginning of the Measurement Period

    AND

  • Must have an encounter finalized by the EP within the first 337 days of the Measurement Period during which they received a diagnosis for uncomplicated low back pain

CPT: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99281, 99282, 99283, 99284, 99285, 98966, 98967, 98968, 98969, 99441, 99442, 99443, 99444, 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 99231, 99232, 99233, 99234, 99235, 99236, 99241, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99318, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99221, 99222, 99223, 99251, 99252, 99253, 99254, 99255, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99024, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337

HCPCS: G0402, G0438, G0439

The patient must have a diagnosis of uncomplicated low back pain. A comprehensive list of eligible diagnosis codes for uncomplicated low back pain can be located here.

A patient will be excluded from this measure if they meet any of the following criteria:

  • Had a diagnosis of HIV or cancer prior to or in the 28 days after the encounter in which they were diagnosed with uncomplicated low back pain
  • Was diagnosed with uncomplicated low back pain in the 180 days before the encounter in which they were diagnosed with uncomplicated low back pain
  • Had a major organ transplant performed prior to or in the 28 days after the encounter in which they were diagnosed with uncomplicated low back pain
  • Had an active diagnosis of trauma in the 90 days prior to or in the 28 days after the encounter in which they were diagnosed with uncomplicated low back pain
  • Had an active diagnosis of IV drug abuse, neurologic impairment, or spinal infection in the 12 months prior to or in the 28 days after the encounter in which they were diagnosed with uncomplicated low back pain
  • Had an active prescription for corticosteroids for at least 90 days in the 12 months prior to the encounter in which they were diagnosed with uncomplicated low back pain

Patients who were in hospice care during the measurement year will also be excluded from the measure.

Diagnoses are documented in the Assessment tab of an encounter. A comprehensive list of eligible diagnosis codes for these exclusions can be located here.

To prescribe a medication, go to Encounter > Medications > Manage/Prescribe Meds > Prescribe a Medication. A comprehensive list of eligible corticosteroids can be located here.

To document a procedure, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add an eligible code. Order Status must be marked as Complete in order to count as an exclusion. A comprehensive list of eligible procedure codes for major organ transplant can be located here.

To document hospice care services as a procedure, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

SNOMED CT: 385763009, 385765002

Order Status must be marked as Complete.

SNOMED CT codes must be added as a Favorite in Preferences > Form Data > Orders to be accessible from the Orders/Referrals tab.

A patient will be counted in the numerator if they did not receive an imaging study on the day of the encounter in which they were diagnosed with uncomplicated low back pain or in the 28 days after the encounter in which they were diagnosed with uncomplicated low back pain.

The imaging studies for uncomplicated low back pain counted for this measure are: MRI of the lower spine, CT scan of the lower spine, and X-ray of the lower spine.

https://ecqi.healthit.gov/ecqm/ep/2018/cms166v7

 

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