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Imaging Studies for Low Back Pain

May 22, 2019

At Blue Cross and Blue Shield of Oklahoma, we are committed to offering support and resources to physicians to achieve the highest level of care possible for their patients. Thank you for your dedication to ensure that your patients receive exceptional care.

Healthcare Effectiveness Data and Information Set (HEDIS®) was developed and is maintained by the National Committee for Quality Assurance (NCQA) to standardize and measure quality for all patients. The Office of Personnel Management (OPM) reviews HEDIS performance of certain measures for Federal Employee Program (FEP) members.

One of these measures looks at using imaging studies for uncomplicated lower back pain. The intent is to evaluate the appropriate use of all diagnostic imaging studies, including x-rays, for uncomplicated new onset lower back pain. Generally, patients with new onset low back pain diagnosis should not receive any imaging within the first 30 days of diagnosis, but rather receive conservative medical treatment with prescription strength analgesics and physical therapy

NCQA realizes that each patient’s presentation is unique, and imaging may be required, and has therefore, added a vast number of medical conditions where imaging could be considered medically necessary on initial patient presentation. If you have such a situation and simply provide that additional diagnosis in your medical evaluation, then your patient with low back pain is excluded from your HEDIS metric, and therefore does not negatively affect your performance for NCQA.

Below we have provided a chart for your review and easy access, to utilize during your low back pain patient visits. We hope this provides one less step in your daily process to evaluate your patients.

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

Heart, Small intestine, Large intestine, Liver, Pancreas islets, Ovaries, Face, Head, Thymus, Spleen, Lungs, Esophagus, Stomach

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

Note: The above list is not all inclusive. For more information visit NCQA.org .

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).