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

Transcription

1 Measure Name: Low Back Pain Imaging Studies Owner: NCQA (LBP) Measure Code: LBP Lab Data: N Rule Description: General Criteria Summary The percentage of patients 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. 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: 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 Age is 18 years or older AND # Evnt Age in Years >= 18 Detailed Criteria As of the beginning of measurement year Age is 50 years or less Age in Years <= 50 As of the end of the measurement year Timeframe Page 1

2 Claim Criteria Condition Description # Evnt Detailed Criteria Timeframe 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 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 From the beginning of the measurement year to 28 days prior to the end of the measurement year 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 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 From the beginning of the measurement year to 28 days prior to the end of the measurement year 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 1 All Diagnosis Codes <> From 6 months (180 days) prior to the date of the index encounter to the date of the index encounter month period prior to the date of the index encounter Table LBP-A: Codes to identify Low Back Pain AND No diagnosis of cancer, for which an imaging study in the presence of low back 1 All Diagnosis Codes <> Table LBP-C: Codes to Identify Exclusions (Clinically Appropriate Indications for Low Back Imaging) Anytime prior to or during the measurement year Page 2

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 1 All Diagnosis Codes <> 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 Condition Description # Evnt Detailed Criteria Timeframe 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 Condition Description No spinal imaging study performed at all OR # Detailed Criteria Evnt 1 CPT Procedure Code <> Table LBP-D: Codes to Identify Imaging Studies and Revenue Code UB <> Table LBP-D: Codes to Identify Imaging Studies Timeframe During the 29 day period from the date of the index encounter through 28 days following the date of the index encounter Page 3

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 = Table LBP-D: Codes to Identify Imaging Studies or Revenue Code UB = Table LBP-D: Codes to Identify Imaging Studies) and All Diagnosis Codes <> During the 29 day period from the date of the index encounter through 28 days following the date of the index encounter Table LBP-A: Codes to identify Low Back Pain 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 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 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 Displacement of lumbar intervertebral disc without myelopathy Schmorl's nodes of lumbar region Degeneration of lumbar or lumbosacral intervertebral disc Other and unspecified disc disorder of lumbar region Spinal stenosis, lumbar region, without neurogenic claudication Spinal stenosis, lumbar region, with neurogenic claudication 7242 Lumbago 7243 Sciatica Page 4

5 7245 Backache unspecified 7246 Disorders of sacrum 7247 Disorders of coccyx Unspecified disorder of coccyx Hypermobility of coccyx 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 Emergency dept visit ED Emergency dept visit ED Emergency dept visit ED Emergency dept visit ED Emergency dept visit ED Osteopathic manipulation Outpatient Osteopathic manipulation Outpatient Osteopathic manipulation Outpatient Osteopathic manipulation Outpatient Osteopathic manipulation Outpatient Chiropractic manipulation Outpatient Page 5

6 98941 Chiropractic manipulation Outpatient Chiropractic manipulation Outpatient Office/outpatient visit, new Outpatient Office/outpatient visit, new Outpatient Office/outpatient visit, new Outpatient Office/outpatient visit, new Outpatient Office/outpatient visit, new Outpatient Office/outpatient visit, est Outpatient Office/outpatient visit, est Outpatient Office/outpatient visit, est Outpatient Office/outpatient visit, est Outpatient Office/outpatient visit, est Outpatient Observation care discharge Outpatient Observation care Outpatient Observation care Outpatient Observation care Outpatient Office consultation Outpatient Office consultation Outpatient Office consultation Outpatient Office consultation Outpatient Office consultation Outpatient Home visit, new patient Outpatient Home visit, new patient Outpatient Home visit, new patient Outpatient Home visit, new patient Outpatient Home visit, new patient Outpatient Home visit, est patient Outpatient Home visit, est patient Outpatient Home visit, est patient Outpatient Home visit, est patient Outpatient Prev visit, new, age Outpatient Prev visit, new, age Outpatient Page 6

7 99395 Prev visit, est, age Outpatient Prev visit, est, age Outpatient Preventive counseling, indiv Outpatient Preventive counseling, indiv Outpatient Preventive counseling, indiv Outpatient Preventive counseling, indiv Outpatient Preventive counseling, group Outpatient Preventive counseling, group Outpatient Health risk assessment test Outpatient Unlisted preventive service Outpatient Work related disability exam Outpatient 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 0522 Rural health home Outpatient Page 7

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 149* Malignant neoplasm of other and ill-defined sites within the lip oral cavity and pharynx Page 8

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 Page 9

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 V109* Unspecified personal history of malignant neoplasm Page 10

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 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 Page 11

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 905* Late effects of musculoskeletal and connective tissue injuries Page 12

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 Crushing injury of back 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 X-ray exam of spine X-ray exam of spine X-ray exam of neck spine X-ray exam of lower spine X-ray exam of lower spine X-ray exam of lower spine X-ray exam of lower spine Ct lumbar spine w/o dye Ct lumbar spine w/dye Ct lumbar spine w/o & w/dye MRI neck spine w/o dye MRI neck spine w/dye MRI chest spine w/o dye MRI chest spine w/dye MRI lumbar spine w/o dye MRI lumbar spine w/dye MRI neck spine w/o & w/dye MRI lumbar spine w/o & w/dye X-ray exam sacroiliac joints Page 13

14 72202 X-ray exam sacroiliac joints 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 0972 Radiology diagnostic Page 14