Imaging Studies for Low Back Pain

Jan. 21, 2020

The National Committee for Quality Assurance (NCQA) collects Healthcare Effectiveness Data and Information Set (HEDIS®) measurements. The data helps us ensure our members receive appropriate care. One of these measures evaluates the appropriate use of imaging studies for uncomplicated low back pain. Low back pain is a common medical problem. Evidence does not support that routine imaging improves outcomes. It may expose members to unnecessary radiation and expense.1

HEDIS Low Back Pain (LBP) Measure Description

The LBP measure evaluates imaging done in the first 28 days after diagnosis. It applies to members 18 to 50 years old with new onset2 pain. Imaging studies include X-ray, MRI and CT scans.

Generally, these patients should not undergo imaging. The preferred conservative medical treatment is prescription strength analgesics and physical therapy.

Low Back Pain with Additional Medical Conditions

Imaging may be necessary for some conditions. Examples and their associated codes are in the chart below. If a member has low back pain and an additional medical condition, provide the additional diagnosis in your documentation. Doing so will exclude the member from the LBP measure and won’t affect your HEDIS score.

DESCRIPTION

ICD-10 CODE

Cancer (active)

All ICD10 “C” codes

Cancer (personal history)

All ICD10 “Z” codes

HIV

B20; Z21

IV Drug Abuse

All ICD10 “F” codes

Kidney transplant

0TY00Z0-0TY00Z2; 0TY10Z0-0TY10Z2

Major Organ Transplant, other than kidney

Esophagus, Face, Head, Heart, Intestine (small or large), Liver, Lungs, Ovaries, Pancreas islets, Spleen, Stomach, Thymus

Neurologic Impairment

G83.4

Spinal Infection, Osteomyelitis, and Discitis

A17.81, G06.1, M46.25-M46.28, M46.35-M46.38, M46.46-M46.48

Trauma/Fractures

All ICD10 “S” codes

1https://www.ncqa.org/hedis/measures/use-of-imaging-studies-for-low-back-pain/ ; Accessed 1/2/2020

2Defined as no prior diagnosis of low back pain in the past six months