What is a Low Back Pain Imaging Tour?

Transcription

1 Measure Name: Low Back Pain Imaging Studies Owner: NCQA (LBP) Measure : LBP Lab Data: N Rule : Applicable Provider Specialty: 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. Family practice, geriatricians, neurologists, internal medicine, orthopedic surgeons 1. Measurement period: 1 year prior to measurement period end date 2. 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 3. Anchor date: The earliest date of service for any outpatient or emergency department encounter with a principal diagnosis of low back pain 4. Gaps in enrollment: No gaps in the enrollment during the continuous enrollment period 5. Medical coverage: Yes 6. Drug coverage: No 7. Attribution time frame: 0-28 days post denominator event on low back pain visits 8. Exclusions apply: Yes 9. Age range: years Summary of changes for In their 2014 specs, NCQA replaced all coding table references with value set references. The following changes were made in the denominator: Added codes , 99387, , and (visit types); and, added HCPCS codes G0402, G0438, and G0439 (visit types). While Place of Service codes are not referenced by NCQA, we will keep these codes in order to eliminate ED visits that result in an admission. 2. In their 2014 specs, NCQA now calls out the exclusions as such, rather than including the exclusionary criteria as part of the denominator. 3. We are correcting a timeframe error in the cancer exclusion, from Any time prior to or during the measurement year to Any time prior to through 28 days following the date of the index encounter Denominator : 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.

2 Eligibility Criteria Condition # Evnt Detailed Criteria Timeframe Age is 18 years Age in Years >= 18 As of the beginning of measurement year older AND Age is 50 years or less Age in Years <= 50 As of the end of the measurement year Condition Descriptio At least one outpatient or observation visit with a principal diagnosis of 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) # Evnt 1 (dx must be on same claim as proc or rev code) 1 (dx must be on same claim as proc or rev code) Detailed Criteria ( Procedure = Outpatient, Observation Value Set Or HCPCS Procedure = Outpatient Value Set Or Revenue UB = Outpatient Value Set) Diagnosis Principal = Low Back Pain Value Set ( Procedure = ED Value Set Or Revenue UB = ED Value Set) Diagnosis Principal = Low Back Pain Value Set Place of Service Medstat <> 21, 25, 51, 55 Timeframe From the beginning of the measurement year to 28 days prior to the end of the measurement year From the beginning of the measurement year to 28 days prior to the end of the measurement year

3 Claim Criteria Condition # Evnt Detailed Criteria Timeframe At least one outpatient or observation visit with a principal diagnosis of low back pain 1 (dx must be on same claim as proc or rev code) ( Procedure = Outpatient, Observation Value Set Or HCPCS Procedure = Outpatient Value Set 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) Or Revenue UB = Outpatient Value Set) Diagnosis Principal = Low Back Pain Value Set ( Procedure = ED Value Set Or Revenue UB = ED Value Set) and From the beginning of the measurement year to 28 days prior to the end of the measurement year Diagnosis Principal = Low Back Pain Value Set Place of Service Medstat <> 21, 25, 51, 55

4 Room and Board Flag <> 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 From the beginning of the measurement year to 28 days prior to the end of the measurement year OR At least one osteopathic manipulative visit with a principal diagnosis of low back pain Procedure = Osteopathic Manipulative Treatment Value Set Diagnosis Principal = Low Back Pain Value From the beginning of the measurement year to 28 days prior to the end of the measurement year 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 s <> Low Back Pain Value Set From 6 months (180 days) prior to the date of the index encounter to the date of the index encounter Exclusion Criteria: Patients who had a diagnosis for which imaging is clinically appropriate. This includes cancer, recent trauma, intravenous drug abuse, or neurologic impairment. Condition Connector Condition # Evnt Detailed Criteria Timeframe AND No diagnosis of cancer, for which an imaging study in the presence of low back pain is clinically indicated 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 s <> Malignant Neoplasms, Other Neoplasms, History of Malignant Neoplasm Value Set 1 All Diagnosis s <> Trauma, IV Drug Abuse, Neurologic Impairment Value Set Any time prior to through 28 days following the date of the index encounter From 12 months prior to the date of the index encounter through 28 days following the date of the index encounter

5 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 # 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 : 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 # Evnt Detailed Criteria Timeframe No spinal imaging study performed at all 1 Procedure <> Imaging Studies Value Set During the 29 day period from the date of the index encounter through 28 days following the date of the index encounter Revenue UB <> Imaging Studies Value Sets OR No spinal imaging study performed for low back pain 1 (dx code must be on same claim as proc code or rev ( Procedure = Imaging Studies Value Set Or Revenue UB = Imaging Studies Value Set) All Diagnosis s <> Low Back Pain Value Set During the 29 day period from the date of the index encounter through 28 days following the date of the index encounter

6 Appendix Low Back Pain Value Set 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 Lumbago Sciatica Backache unspecified Disorders of sacrum Disorders of coccyx Unspecified disorder of coccyx Hypermobility of coccyx Other disorders of coccyx Other acquired deformity of back or spine Nonallopathic lesions of lumbar region not elsewhere classified Nonallopathic lesions of sacral region not elsewhere classified Sprains and strains of sacroiliac region Lumbosacral (joint) (ligament) sprain Sacroiliac (ligament) sprain Sacrospinatus (ligament) sprain Sacrotuberous (ligament) sprain Other specified sites of sacroiliac region sprain Unspecified site of sacroiliac region sprain Lumbar sprain

7 Osteopathic Manipulative Treatment Value Set Osteopathic manipulative treatment Spinal manipulative treatment Outpatient Value Set New patient, office or other outpatient service Established patient, office or other outpatient service Hospital observation services, observation care discharge services Office or other outpatient consultations, New or established patient Home services, New patient Home services, Established patient Init Pm E/M - New Pat - Inf Init Pm E/M - New Pat 1-4 Yrs Prev Visit - New - Age Preventive medicine services, years, new patient Per Pm Reeval - Est Pat - Inf Prev Visit - Est - Age Prev Visit - Est - Age Preventive medicine services, years, established patient Preventive medicine, individual counseling, new or established, 15 min Preventive medicine, individual counseling, new or established, 30 min Preventive medicine, individual counseling, new or established, 45 min Preventive medicine, individual counseling, new or established, 60 min Preventive medicine, group counseling, 30 min Preventive medicine, group counseling, 60 min Other preventive medicine services, administration and interpretation Other preventive medicine services, unlisted 99455, Work related or medical disability evaluation services G0402 HCPCS Initial preventive physical; f-f visit, new

8 G0438 HCPCS Annual wellness visit; personalized prevention plan, initial G0439 HCPCS Annual wellness visit; personalized prevention plan, subsequent 0510 CLINIC 0511 CHRONIC PAIN CL 0512 DENTAL CLINIC 0513 PSYCH CLINIC 0514 OB-GYN CLINIC 0515 PEDS CLINIC 0516 URGENT CLINIC 0517 FAMILY CLINIC 0519 OTHER CLINIC 0520 FREESTAND CLINIC 0521 RURAL/CLINIC 0522 RURAL/HOME 0523 FR/STD FAMILY CLINIC 0526, 0527, 0528 FR/STD URGENT CLINIC 0529 OTHER FR/STD CLINIC 0982 PRO FEE/OUTPT 0983 PRO FEE/CLINIC Observation Value Set Observation Care Discharge Observation Care ED Value Set Emergency services, new or established patient 0450 EMERG ROOM 0451 ER/EMTALA 0452 ER/BEYOND EMTALA 0456 URGENT CARE 0459 OTHER EMER ROOM 0981 PRO FEE/ER

9 Malignant Neoplasm Value Set 140* 141* Malignant neoplasm of lip 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 with in the kip, oral cavity, and pharynx 150* Malignant neoplasmof 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 of liver and interhepatic bile ducts 156* Malignant neoplasm of gallbladder and extrahepatic bile ducts 157* Malignant neoplasm of pancreas 158* Malignant neoplasm of retroperitoneum and peritoneum 159* Malignant neoplasm of other and ill-defined sites within the digestive organs and peritoneum 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 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 and unspecified malignant neoplasm of the skin 174* Malignant neoplasm of female breast 175* Malignant neoplasm of male breast 176* Kaposi'ssarcoma

10 179 Malignant neoplasmof 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 the nervous system 193 Malignant neoplasm of thyroid gland 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 and other specified malignant tumors of lymphatic tissue 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* Neuroendocrinetumors

11 Other Neoplasms Value Set 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* Uncertain behavior of neoplasm of bone 239* Neoplasm NOS History of Malignant Neoplasm Value Set V10* Personal history of malignant neoplasm IV Drug Abuse Value Set 304.0, Opioid type dependence 304.1, sedative, hypnotic or anxiolytic dependence 304.2, Cocaine dependence Amphetamine and other psychostimulant dependence 305.4, Nondependent sedative, hypnotic or anxiolytic abuse 305.5, Nondependent opioid abuse 305.6, Nondependent cocaine abuse 305.7, Nondependent amphetamine or related acting sympathomimetic abuse

12 Neurologic Impairment Value Set Cauda equina syndrome NOS Neuralgia/neuritis NOS Trauma Value Set : 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 818* Ill-defined fractures of upper limb 819* Multiple fractures involving both upper limbs and upper limb with rib(s) 820* Fracture of neck of femur

13 821* 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 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 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

14 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 Imaging Studies Value Set 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 X-ray exam sacroiliac joints X-ray exam of sacrum and coccyx Radiology - Diagnostic Other Computerized Tomography (CT Scan)

15 Body scan Other CT scans Magnetic Resonance Imaging (MRI) MRI spinal cord (including spine) MRI other Other Radiology diagnostic