Measure Set One Specifications

The 2009 hospital outpatient prospective payment system (OPPS) final rule published November 18, 2008 now requires that the annual OPPS payment inflation update be reduced by 2.0 percentage points for certain hospitals that do not meet quality reporting requirements. The final rule adopts 4 new quality measures for imaging efficiency, which are claims based, increasing the number of quality measures that OPPS hospitals must report in CY 2009 to receive the full update in CY 2010 from the current 7 measures to 11 measures.

Note that these measures are measured at the outpatient hospital facility level. The measures are also based on all Medicare fee-for-service claims data paid under the outpatient prospective payment system and there is no stratification or risk adjustment applied.

Title of Measure: Use of Contrast: Abdomen CT

Brief Description of Measure:

Estimate the ratio of combined (with and without) studies to total studies performed. A high value would indicate a high use of combination studies and raise the question of inefficient examination protocols. Results to be segmented based upon data availability by facility.

This measure calculates the percentage of abdomen studies that are performed with and without contrast out of all abdomen studies performed (those with contrast, those without contrast, and those with both). The intent of this measure is to assess questionable utilization of contrast agents that carry an element of risk and significantly increase examination cost. While there may be a direct financial benefit to the service provider for the use of contrast agents due to increased reimbursements for "combined" studies, this proposed measure is directed at the identification of those providers who typically employ interdepartmental/facility protocols that call for its use in nearly all cases. The mistaken concept is that more information is always better than not enough.

Numerator Statement:

The number of Abdomen CT studies with and without contrast (combined studies).

Denominator Statement:

The number of Abdomen CT studies performed (with contrast, without contrast or both with and without contrast).

Denominator Exclusions:

Patients with diagnoses related to unspecified disorder of kidney and ureter, hematuria, pancreatic disorders, adrenal mass, malignant neoplasms of liver and intrahepatic bile ducts, and neoplasms of the pancreas, kidney, and liver.

Numerator Codes:

CPT - 74170 – Abdomen CT With and Without Contrast

Denominator Codes:

74150 - Abdomen CT Without Contrast Material
74160 – Abdomen CT With Contrast Material
74170 – Abdomen CT With and Without Contrast MATERIAL

Denominator Exclusion Codes:

Patients with the following ICD9 diagnoses:

593.9 Unspecified disorder of kidney and ureter

Hematuria:

599.7 Benign, essential, idiopathic
120.0 Schistosoma haematobium

Pancreatic:

251.2  Hypoglycemia, unspecified
251.0  Hypoglycemia with coma
250.8  In diabetes mellitus
270.3  Leucine-induced

Adrenal mass:

255.9 Unspecified disorder of adrenal glands

Malignant Neoplasms of liver and intrahepatic bile ducts:

155.0  Liver, primary
155.1  Intrahepatic bile ducts
155.2  Liver, not specified as primary or secondary

Malignant Neoplasm of Pancreas

157.0  Head of Pancreas
157.1  Body of Pancreas
157.2  Tail of Pancreas
157.3  Pancreatic Duct
157.4  Islets of Langerhans
157.8  Other specific sites of pancreas
157.9  Pancreas, part unspecified
189.0  Malignant Neoplasm of Kidney
211.5  Benign neoplasm of liver and biliary passages
211.6  Pancreas, except islets of Langerhans
211.7  Islets of Langerhans
223.0  Benign neoplasm of kidney except pelvis

Title of Measure: Use of Contrast: Thorax CT

Brief Description of Measure:

Estimate the ratio of combined (with and without) studies to total studies performed. A high value would indicate a high use of combination studies. Results to be segmented based upon data availability by facility.

This measure calculates the percentage of thorax studies that are performed with and without contrast out of all thorax studies performed (those with contrast, those without contrast, and those with both). The intent of this measure is to assess questionable utilization of contrast agents that carry an element of risk and significantly increase examination cost. While there may be a direct financial benefit to the service provider for the use of contrast agents due to increased reimbursements for "combined" studies, this proposed measure is directed at the identification of those providers who typically employ interdepartmental/facility protocols that call for its use in nearly all cases. The mistaken concept is that more information is always better than not enough. The focus of this measure is one of the specific body parts where the indications for contrast material are more specifically defined.

Numerator Statement:

The number of thorax CT studies with and without contrast (combined studies).

Denominator Statement:

The number of thorax CT studies performed (with contrast, without contrast or both with and without contrast).

Denominator Exclusions:

None

Numerator Codes:

71270 – Thorax CT With and Without Contrast

Denominator Codes:

71250 - Thorax Without Contrast
71260 – Thorax CT With Contrast
71270 – Thorax CT With and Without Contrast

Denominator Exclusion Codes:

None

Title of Measure: MRI Lumbar Spine for Low Back Pain

Brief Description of Measure:

This measure estimates the percentage of people who had an MRI of the Lumbar Spine with a diagnosis of low back pain without claims based evidence of antecedent conservative therapy.

Numerator Statement:

Patients who had an MRI of the Lumbar Spine with a diagnosis of low back pain without claims based evidence of antecedent conservative therapy

Denominator Statement:

Patients who had an MRI of the Lumbar Spine with a diagnosis of low back pain

Denominator Exclusions:

Lumbar Spine MRI studies without a diagnosis related to low back pain

Numerator Codes:

CPT codes:

72148 – MRI Lumbar Spine Without Contrast;
72149 – MRI Lumbar Spine With Contrast;
72158 – MRI Lumbar Spine With and Without Contrast

Indications of claims based antecedent conservative therapy include any procedure codes in the three following groups:

1. Claim(s) in the 60 days preceding the Lumbar Spine MRI for physical therapy.

CPT codes:

97110 – Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercise to develop strength and endurance, range of motion and flexibility;
97112 – neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities;
97113 – aquatic therapy with therapeutic exercises;
97124 – massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion);
97140 – Manual therapy technical (eg mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes.

2. Claim(s) in the 60 days preceding the Lumbar Spine MRI for chiropractic evaluation and manipulative treatment.

CPT codes:

98940 – Chiropractic manipulative treatment (CMT); spinal, one to two regions;
98941 – spinal, three to four regions;
98942 – spinal, five regions;
98943 – extraspinal, one or more regions.

3. Claim(s) >28 days and <60 days preceding the Lumbar Spine MRI for low back pain evaluation and management.

CPT codes:

99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99354-99357, 99385-99387, 99395-99397, 99401-99404, 99455-99456, 99499

Billed with a diagnosis (ICD9):

721.3    Lumbosacral spondylosis without myelopathy
721.90  Spondylosis of unspecified site without mention of myelopathy
722.10  Displacement of lumbar intervertebral disc without myelopathy
722.52  Degeneration of lumbar or lumbosacral intervertebral disc
722.6    Degeneration of intervertebral disc, site unspecified
722.93  Other unspecified disco disorder of lumbar region
724.02  Spinal stenosis of lumbar region
724.2    Lumbago
724.3    Sciatica
724.5    Unspecified backache
724.6    Disorders of sacrum
724.70  Unspecified disorder of coccyx
724.71  Hypermobility of coccyx
724.79  Other disorder of the coccyx
738.5    Other acquired deformity of back or spine
739.3    Nonallopathic lesion of lumbar region, not elsewhere classified
739.4    Nonallopathic lesion of sacral regions, not elsewhere classified
846.0    Sprain and strain of lumbosacral (joint) (ligament)
846.1    Sprain and strain of sacroiliac (ligament)
846.2    Sprain and strain of sacrospinatus (ligament)
846.3    Sprain and strain of sacrotuberous (ligament)
846.8    Other specified sites of sacroiliac region sprain and strain
846.9    Unspecified site of sacroiliac region sprain and strain
847.2    Lumbar sprain and strain

Denominator Codes:

CPT codes:

72148 – MRI Lumbar Spine Without Contrast;
72149 – MRI Lumbar Spine With Contrast;
72158 – MRI Lumbar Spine With and Without Contrast

Billed with a diagnosis (ICD-9):

Denominator Exclusion Codes:

Patients with ICD-9 codes:

Cancer:

140-208, 230-234, 235-239

Trauma:

800, 839, 850-854, 860-869, 905-909, 926.11, 926.12, 929, 952, 958-959

IV Drug Abuse:

304.0, 304.1X, 304.2X, 304.4X, 305.4X, 305.5X, 305.6X, 305.7X

Neurologic Impairment:

344.60, 729.2

Human Immunodeficiency Virus (HIV):

042-044

Unspecified Immune Deficiencies:

279.3

Intraspinal abscess:

324.9, 324.1

Title of Measure: Mammography Follow Up Rates

Brief Description of Measure:

This measure calculates the percentage of patients with mammography screening studies that are followed by a diagnostic mammography or ultrasound of the breast study in an outpatient or office setting. An abnormally high rate of "call-backs" from indeterminate screening studies may be an indication of the inability of the reader to adequately determine when additional imaging is necessary (high false positive rate). This points to the experience and confidence of the interpreting physician and indicates both quality and efficiency, although a recent survey of 1,570 women concluded that "a substantial fraction of women in this study would have preferred the inconvenience of and anxiety associated with a higher recall rate if it resulted in the possibility of detecting breast cancer earlier." Recall rates with follow-up "diagnostic" mammography studies greater than 10 to 14 percent are generally felt to be unusual unless explained by the morbidity of the underlying population.

Numerator Statement:

The number of patients who had a diagnostic mammography study or an ultrasound of the breast study following a screening mammography study (within 45 days).

Denominator Statement:

The number of patients who had received a screening mammography study.

Denominator Exclusions:

None

Numerator Codes:

Diagnostic Mammography Study

HCPC: 76090, 76091, 77055*, 77056*, G0204, G0206

Ultrasound of the Breast Study:

CPT: 76645

The study must be 0-45 days following a screening mammography study:

HCPC 76092, 77057*, G0202

*Effective Jan 1, 2007 CMS assigned new CPT codes for screening and diagnostic mammography services. CPT codes 76090, 76091, 76092 were replaced with 77055, 77056, 77057.

Denominator Codes:

Screening Mammography Study:

HCPC: 76092, 77057*, G0202

*Effective Jan 1, 2007 CMS assigned new CPT codes for screening and diagnostic mammography services. CPT codes 76090, 76091, 76092 were replaced with 77055, 77056, 77057.

Denominator Exclusion Codes:

None

Questions and comments regarding the Measure Set One specifications may be emailed to Imaging.Measures@lewin.com. Note that CMS contracted with L&M Policy Research, LLC, to develop this initial set of imaging efficiency measures. The Lewin Group, its subcontractor Dobson|DaVanzo, and National Imaging Associates were subcontracted by L&M to support this effort.