Measure Name: Low Back Pain Imaging Studies Measure Code: LBP Lab Data: N

(1)

Measure Name: Low Back Pain Imaging Studies Owner: NCQA (LBP)

Measure Code: LBP Lab Data: N

Rule Description: The percentage of patients 18-50 years of age who had a principal diagnosis of low back pain and who did not have an imaging study (plain x-ray, MRI, CT scan) within 28 days of the diagnosis.

General Criteria Summary

1. Continuous enrollment: From 6 months (180 days) prior to the date of the index encounter through 28 days following the date of the index encounter 2. Anchor date: The earliest date of service for any outpatient or emergency department encounter with a principal diagnosis of low back pain 3. Gaps in enrollment: No gaps in the enrollment during the continuous enrollment period

4. Medical coverage: Yes 5. Drug coverage: No

6. Attribution time frame: 0-28 days post denominator event on low back pain visits 7. Exclusions apply: Yes

8. Age range: 18-50 years

Summary of changes for 2013 No changes

--- Denominator Description: All patients, aged 18 years as of the beginning of the measurement period to 50 years as of the end of the measurement period, who had an outpatient or emergency department encounter with a principal diagnosis of low back pain

Inclusion Criteria: Patients, aged 18 years as of the beginning of the measurement year to 50 years as of the end of the measurement year, who had at least one outpatient or emergency department encounter with a principal diagnosis of low back pain during the intake period, had no low back pain diagnosis during the six month (180 day) period prior to the first low back pain encounter, and had no diagnosis for which an imaging study in the presence of low back pain is clinically indicated. The intake period is from the beginning of the measurement year to 28 days prior to the end of the measurement year.

Eligibility Criteria

Condition Description

# Evnt

Detailed Criteria Timeframe

Age is 18 years or older

Age in Years >= 18 As of the beginning of measurement year

AND

(2)

Claim Criteria

# Evnt

At least one outpatient visit with a principal diagnosis of low back pain 1 (dx must be on same claim as proc or rev code) (CPT Procedure Code =

Table LBP-B: Codes to identify Visit Type

From the beginning of the measurement year to 28 days prior to the end of the measurement year

Or

Revenue Code UB =

Table LBP-B: Codes to identify Visit Type)

And

Diagnosis Code Principal =

Table LBP-A: Codes to identify Low Back Pain

OR

At least one

emergency department visit with a principal diagnosis of low back pain (ED visit cannot be part of an admission) 1 (dx must be on same claim as proc or rev code) (CPT Procedure Code =

Table LBP-B: Codes to identify Visit Type

From the beginning of the measurement year to 28 days prior to the end of the measurement year

Or

Revenue Code UB =

Table LBP-B: Codes to identify Visit Type)

and

Diagnosis Code Principal =

and

Room and Board Flag Code <> 1 on a facility claim with a Date of First Service equal to or one day greater than the Date of First Service on a claim identified through the above criteria

Note: Identify all visits that meet the above criteria. Then select the encounter with the earliest date and use that as the index encounter before checking the remaining inclusion criteria.

AND

No low back pain diagnosis during the 6 month period prior to the date of the index encounter

1 All Diagnosis Codes <>

From 6 months (180 days) prior to the date of the index encounter to the date of the index encounter

AND

No diagnosis of cancer, for which an imaging study in the presence of low back

Table LBP-C: Codes to Identify Exclusions (Clinically Appropriate Indications for Low Back Imaging)

(3)

pain is clinically indicated

AND

No diagnosis of trauma, IV drug abuse, or neurologic

impairment, for which an imaging study in the presence of low back pain is clinically indicated

Table LBP-C: Codes to Identify Exclusions (Clinically Appropriate Indications for Low Back Imaging)

From 12 months prior to the date of the index encounter through 28 days following the date of the index encounter

Continuous Enrollment Criteria: Patients continuously enrolled with medical coverage from six months (180 days) prior to the date of the low back pain index encounter through 28 days following that date

# Evnt

Continuous enrollment Continuous Enrollment is 208 days out of 208 days From 6 months (180 days) prior to the date of the index encounter through 28 days following the date of the index encounter

AND

Has medical coverage Coverage Indicator Medical = Y From 6 months (180 days) prior to the date of the index encounter through 28 days following the date of the index encounter

--- Numerator Description: For each patient who meets the denominator criteria, those who did not receive an imaging study for low back pain on the date of the index encounter or in the 28 days following that date

Inclusion Criteria: Patients who did not have an imaging study for low back pain during the period from the date of the index encounter through 28 days following the date of the index encounter

# Evnt

No spinal imaging study performed at all

1 CPT Procedure Code <>

Table LBP-D: Codes to Identify Imaging Studies

During the 29 day period from the date of the index encounter through 28 days following the date of the index encounter

and

Revenue Code UB <>

(4)

No spinal imaging study performed for low back pain

1 (dx code must be on same claim as proc code or rev code) (CPT Procedure Code =

During the 29 day period from the date of the index encounter through 28 days following the date of the index encounter

or

Revenue Code UB =

Table LBP-D: Codes to Identify Imaging Studies)

and

All Diagnosis Codes <>

Notes:

1.The intake period is 28 days less than a full year. For example, if the measurement year starts on January 1, the intake period runs from January 1 through December 3. 2.In their 2010/2011 specs, NCQA removed revenue code 077* from the list of codes for outpatient visit types.

3.In their 2010/2011 specs, NCQA added diagnosis code 209* to the list of codes for cancer exclusions. 4.In 2012, ICD-9 Diagnosis code 724.03 was added to Table LBP-A.

5.Do not include ED visits that result in an inpatient admission.

Appendix

Table LBP-A: Codes to identify Low Back Pain

ICD-9 Diagnosis

codes Description: Low Back Pain

7213 Lumbosacral spondylosis without myelopathy

72210 Displacement of lumbar intervertebral disc without myelopathy 72232 Schmorl's nodes of lumbar region

72252 Degeneration of lumbar or lumbosacral intervertebral disc 72293 Other and unspecified disc disorder of lumbar region

72402 Spinal stenosis, lumbar region, without neurogenic claudication 72403 Spinal stenosis, lumbar region, with neurogenic claudication

7242 Lumbago

(5)

7245 Backache unspecified 7246 Disorders of sacrum 7247 Disorders of coccyx

72470 Unspecified disorder of coccyx 72471 Hypermobility of coccyx 72479 Other disorders of coccyx

7385 Other acquired deformity of back or spine

7393 Nonallopathic lesions of lumbar region not elsewhere classified 7394 Nonallopathic lesions of sacral region not elsewhere classified 846 Sprains and strains of sacroiliac region

8460 Lumbosacral (joint) (ligament) sprain 8461 Sacroiliac (ligament) sprain

8462 Sacrospinatus (ligament) sprain 8463 Sacrotuberous (ligament) sprain

8468 Other specified sites of sacroiliac region sprain 8469 Unspecified site of sacroiliac region sprain

8472 Lumbar sprain

Table LBP-B: Codes to identify Visit Type

CPT Procedure

Code Description: Visit Types Description

99281 Emergency dept visit ED

98925 Osteopathic manipulation Outpatient

(6)

98941 Chiropractic manipulation Outpatient

98942 Chiropractic manipulation Outpatient

99201 Office/outpatient visit, new Outpatient

99211 Office/outpatient visit, est Outpatient

99217 Observation care discharge Outpatient

99218 Observation care Outpatient

99241 Office consultation Outpatient

99341 Home visit, new patient Outpatient

99347 Home visit, est patient Outpatient

99385 Prev visit, new, age 18-39 Outpatient

(7)

99395 Prev visit, est, age 18-39 Outpatient

99396 Prev visit, est, age 40-64 Outpatient

99401 Preventive counseling, indiv Outpatient

99411 Preventive counseling, group Outpatient

99412 Preventive counseling, group Outpatient

99420 Health risk assessment test Outpatient

99429 Unlisted preventive service Outpatient

99455 Work related disability exam Outpatient

99456 Disability examination Outpatient

UB Revenue code Description: Visit Type Description

0450 Emergency Room (ER) ED

0451 EMTALA emergency medical screening ED

0452 ER beyond EMTALA screening ED

0456 Urgent Care ED

0459 Other emergency room ED

0981 Emergency Room (ER) ED

0510 Clinic Outpatient

0511 Chronic pain center Outpatient

0512 Dental clinic Outpatient

0513 Psychiatric clinic Outpatient

0514 OB/Gyn clinic Outpatient

0515 Pediatric clinic Outpatient

0516 Urgent care clinic Outpatient

0517 Family practice clinic Outpatient

0519 Other clinic Outpatient

0520 Free-Standing Clinic Outpatient

0521 Rural health clinic Outpatient

(8)

0523 Family practice clinic Outpatient

0526 Urgent care clinic Outpatient

0527 Rural Health – visiting nurse Outpatient

0528 Rural Health – other site Outpatient

0529 Other freestanding clinic Outpatient

0570 Home Health Aide Outpatient

0571 Visit charge Outpatient

0572 Hourly charge Outpatient

0579 Other home health aide Outpatient

0580 Other Visits (Home Health) Outpatient

0581 Visit charge Outpatient

0582 Hourly charge Outpatient

0583 Other (Assessment) Outpatient

0589 Other home health visits Outpatient

0590 Units of Service (Home Health) Outpatient

0599 Home Health Other Units Outpatient

0982 Outpatient Services Outpatient

0983 Clinic Outpatient

Table LBP-C: Codes to Identify Exclusions (Clinically Appropriate Indications for Low Back Imaging)

ICD-9-CM

Diagnosis code Description: Cancer

140* Malignant neoplasm of lip 141* Malignant neoplasm of tongue

142* Malignant neoplasm of major salivary glands 143* Malignant neoplasm of gum

144* Malignant neoplasm of floor of mouth

145* Malignant neoplasm of other and unspecified parts of mouth 146* Malignant neoplasm of oropharynx

147* Malignant neoplasm of nasopharynx 148* Malignant neoplasm of hypopharynx

(9)

150* Malignant neoplasm of esophagus 151* Malignant neoplasm of stomach

152* Malignant neoplasm of small intestine including duodenum 153* Malignant neoplasm of colon

154* Malignant neoplasm of rectum rectosigmoid junction and anus 155* Malignant Neoplasm Liver

156* Mal Neo Gb/Extrahepatic 157* Malignant Neo Pancreas 158* Malig Neo Peritoneum 159* Oth Malig Neo Gi/Periton

160* Malignant neoplasm of nasal cavities middle ear and accessory sinuses 161* Malignant neoplasm of larynx

162* Malignant neoplasm of trachea bronchus and lung 163* Malignant neoplasm of pleura

164* Malignant neoplasm of thymus heart and mediastinum

165* Malignant neoplasm of other and ill-defined sites within the respiratory system and intrathoracic organs 170* Malignant neoplasm of bone and articular cartilage

171* Malignant neoplasm of connective and other soft tissue 172* Malignant melanoma of skin

173* Other malignant neoplasm of skin 174* Malignant neoplasm of female breast 175* Malignant neoplasm of male breast

176* Kaposi's sarcoma

179* Malignant neoplasm of uterus-part unspecified 180* Malignant neoplasm of cervix uteri

181* Malignant neoplasm of placenta 182* Malignant neoplasm of body of uterus

183* Malignant neoplasm of ovary and other uterine adnexa

184* Malignant neoplasm of other and unspecified female genital organs 185* Malignant neoplasm of prostate

186* Malignant neoplasm of testis

187* Malignant neoplasm of penis and other male genital organs 188* Malignant neoplasm of bladder

189* Malignant neoplasm of kidney and other and unspecified urinary organs 190* Malignant neoplasm of eye

191* Malignant neoplasm of brain

192* Malignant neoplasm of other and unspecified parts of nervous system 193* Malignant neoplasm of thyroid gland

(10)

194* Malignant neoplasm of other endocrine glands and related structures 195* Malignant neoplasm of other and ill-defined sites

196* Secondary and unspecified malignant neoplasm of lymph nodes 197* Secondary malignant neoplasm of respiratory and digestive systems 198* Secondary malignant neoplasm of other specified sites

199* Malignant neoplasm without specification of site 200* Lymphosarcoma and reticulosarcoma

201* Hodgkin's disease

202* Other malignant neoplasms of lymphoid and histiocytic tissue 203* Multiple myeloma and immunoproliferative neoplasms

204* Lymphoid leukemia

205* Myeloid leukemia

206* Monocytic leukemia

207* Other specified leukemia 208* Leukemia of unspecified cell type 209* Neuroendocrine tumors

230* Carcinoma in situ of digestive organs 231* Carcinoma in situ of respiratory system 232* Carcinoma in situ of skin

233* Carcinoma in situ of breast and genitourinary system 234* Carcinoma in situ of other and unspecified sites

235* Neoplasm of uncertain behavior of digestive and respiratory systems 236* Neoplasm of uncertain behavior of genitourinary organs

237* Neoplasm of uncertain behavior of endocrine glands and nervous system 238* Neoplasm of uncertain behavior of other and unspecified sites and tissues

239*

Neoplasms Of Unspecified Nature V10 Personal history of malignant neoplasm

V100* Personal history of malignant neoplasm of gastrointestinal tract V101* Personal history of malignant neoplasm of trachea bronchus and lung

V102* Personal history of malignant neoplasm of other respiratory and intrathoracic organs V103 Personal history of malignant neoplasm of breast

V104* Personal history of malignant neoplasm of genital organs V105* Personal history of malignant neoplasm of urinary organs V106* Personal history of leukemia

V107* Personal history of other lymphatic and hematopoietic neoplasms V108* Personal history of malignant neoplasm of other sites

(11)

ICD-9-CM

Diagnosis code Description: IV Drug Abuse

3040* Opioid type dependence

3041* sedative, hypnotic or anxiolytic dependence 3042* Cocaine dependence

3044* Amphetamine and other psychostimulant dependence 3054* Nondependent sedative, hypnotic or anxiolytic abuse 3055* Nondependent opioid abuse

3056* Nondependent cocaine abuse

3057* Nondependent amphetamine or related acting sympathomimetic abuse

ICD-9-CM _{Description: Neurologic Impairment}

34460 Cauda equina syndrome without neurogenic bladder 7292 Neuralgia neuritis and radiculitis unspecified

ICD-9-CM

Diagnosis code Description: Trauma

800* Fracture of vault of skull 801* Fracture of base of skull 802* Fracture of face bones

803* Other and unqualified skull fractures

804* Multiple fractures involving skull or face with other bones 805* Fracture of vertebral column without mention of spinal cord injury 806* Fracture of vertebral column with spinal cord injury

807* Fracture of rib(s) sternum larynx and trachea 808* Fracture of pelvis

809* Ill-defined fractures of bones of trunk 810* Fracture of clavicle

811* Fracture of scapula 812* Fracture of humerus 813* Fracture of radius and ulna 814* Fracture of carpal bone(s) 815* Fracture of metacarpal bone(s)

816* Fracture of one or more phalanges of hand 817* Multiple fractures of hand bones

(12)

818* Ill-defined fractures of upper limb

819* Multiple fractures involving both upper limbs and upper limb with rib(s) and sternum 820* Fracture of neck of femur

821* Fracture of other and unspecified parts of femur 822* Fracture of patella

823* Fracture of tibia and fibula 824* Fracture of ankle

825* Fracture of one or more tarsal and metatarsal bones 826* Fracture of one or more phalanges of foot

827* Other multiple and ill-defined fractures of lower limb

828* Multiple fractures involving both lower limbs lower with upper limb and lower limb(s) with rib(s) and sternum 829* Fracture of unspecified bones

830* Dislocation of jaw 831* Dislocation of shoulder 832* Dislocation of elbow 833* Dislocation of wrist 834* Dislocation of finger 835* Dislocation of hip 836* Dislocation of knee 837* Dislocation of ankle 838* Dislocation of foot

839* Other multiple and ill-defined dislocations

850* Concussion

851* Cerebral laceration and contusion

852* Subarachnoid subdural and extradural hemorrhage following injury 853* Other and unspecified intracranial hemorrhage following injury 854* Intracranial injury of other and unspecified nature

860* Traumatic pneumothorax and hemothorax 861* Injury to heart and lung

862* Injury to other and unspecified intrathoracic organs 863* Injury to gastrointestinal tract

864* Injury to liver 865* Injury to spleen 866* Injury to kidney 867* Injury to pelvic organs

868* Injury to other intra-abdominal organs

869* Internal injury to unspecified or ill-defined organs

(13)

906* Late effects of injuries to skin and subcutaneous tissues 907* Late effects of injuries to the nervous system

908* Late effects of other and unspecified injuries 909* Late effects of other and unspecified external causes 92611 Crushing injury of back

92612 Crushing injury of buttock

929* Crushing injury of multiple and unspecified sites 952* Spinal cord injury without evidence of spinal bone injury 958* Certain early complications of trauma

959* Injury other and unspecified

Table LBP-D: Codes to Identify Imaging Studies

CPT Procedure

code Description: Imaging Studies

72010 X-ray exam of spine 72020 X-ray exam of spine 72052 X-ray exam of neck spine 72100 X-ray exam of lower spine 72110 X-ray exam of lower spine 72114 X-ray exam of lower spine 72120 X-ray exam of lower spine 72131 Ct lumbar spine w/o dye 72132 Ct lumbar spine w/dye 72133 Ct lumbar spine w/o & w/dye 72141 MRI neck spine w/o dye 72142 MRI neck spine w/dye 72146 MRI chest spine w/o dye 72147 MRI chest spine w/dye 72148 MRI lumbar spine w/o dye 72149 MRI lumbar spine w/dye 72156 MRI neck spine w/o & w/dye 72158 MRI lumbar spine w/o & w/dye 72200 X-ray exam sacroiliac joints

(14)

72202 X-ray exam sacroiliac joints 72220 X-ray exam of sacrum and coccyx

UB Revenue code Description: Imaging Studies

0320 Radiology - Diagnostic

0329 Other

0350 Computerized Tomography (CT Scan)

0352 Body scan

0359 Other CT scans

0610 Magnetic Resonance Imaging (MRI) 0612 MRI spinal cord (including spine)

0614 MRI – other

0619 Other