HEDIS tips: Use of Imaging Studies for Low Back Pain (LBP)

What is the measure?

The measure assesses members aged 18 to 75 who have a primary diagnosis of uncomplicated low back pain, who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of diagnosis, in any of the following settings:

• Office visits, outpatient evaluations, telemedicine/telehealth visits, emergency department visits, and observation level care
• Physical therapy and/or osteopathic and/or chiropractic manipulative treatment

We recognize that providers know that even the simplest complaints of low back pain are never just simple visits for low back pain. Realizing that each patient is unique, and imaging may be required, NCQA has added several medical conditions where imaging could be medically necessary.

By simply providing the additional diagnosis (Table 2) in your medical evaluation, your patient with low back pain is excluded from the HEDIS^® metric.

Common measurement triggers*

Table 1: Common ICD-10-CM codes that trigger patients into the HEDIS measure are:

*This is a list of commonly used codes. Other codes not listed here related to low back pain may trigger HEDIS measures.

Common exclusions

There are several diagnoses that will remove the member from the LBP HEDIS measure if imaging is done within 28 days of the diagnosis for medical necessity. It is important to include additional diagnoses as appropriate.

Table 2: Common ICD-10-CM codes that exclude patients from the LBP HEDIS measure are:

Note: These lists are not all-inclusive. This information is not about a change in policy but a reference to quality improvement activities.

Helpful tips:

• Avoid ordering diagnostic studies in the first four weeks of new-onset back pain in the absence of red flags.
• Use correct exclusion codes where necessary.
• Make timely submission of claims and encounter data.
• Be aware of the exclusions listed above.