Product Lines:
Advantage MD, EHP, Priority Partners, and USFHP.

Measurement Period: January 1 - December 31
 
Description:
The percentage of persons 18–75 years of age with a principal diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.

Stratifications: 
Age as of the last day of measurement period.

• 18–64 years.
• 65–75 years.

Measure Reporting:
HealthChoice Performance Measure reporting for Priority Partners.

Improvement Notation:
Increased score indicates improvement.

Note: Reported as an inverted rate [1– (numerator/denominator)]. 
A higher score indicates appropriate treatment of low back pain (i.e., the proportion for whom imaging studies did not occur).

Data Collection:

• Administrative.

Note: Supplemental data may not be used for this measure, except for denominator exclusions.

Initial Population:

• Measure Item Count: Person.
• Age:18–75 years of age as of the last day of the measurement period.
• Benefits: Medical.
• Continuous Enrollment: 180 days prior to the IESD through 28 days after the IESD.
• Allowable Gap: None.

Definition: 
IESD- Index Episode Start Date: Earliest date of service for an eligible encounter during the Intake Period with a principal diagnosis of low back pain.

Intake Period: January 1–December 3 of the measurement period. The intake period is used to identify the first eligible encounter with a principal diagnosis of low back pain.

Negative Diagnosis History: A period of 180 days (6 months) prior to the IESD when the person had no claims/encounters with any diagnosis of low back pain.

Denominator:
Low back pain diagnosis.
Persons with a principal diagnosis of uncomplicated low back pain during the intake period. 

Numerator:
An imaging study with a diagnosis of uncomplicated low back pain.
An imaging study with a diagnosis of uncomplicated low back pain on the IESD or in the 28 days following the IESD. 

Best Practice and Measure Tips

• This measure is reported as an inverted measure.
• A higher score indicates appropriate treatment of low back pain (i.e., the proportion for whom imaging studies did not occur). 
• Avoid ordering diagnostic studies within 30 days of a diagnosis of new-onset back pain in the absence of measure exclusions. 
• Use correct exclusion codes as applicable.
• First-line treatment should emphasize conservative measures.  
• Provide patient education on cautious and responsible pain relief, activity level, stretching exercises, use of heat.
• Physical Therapy referral, including massage, stretching, strengthening exercises and manipulation.
• Comorbid conditions such as sleep disorders, anxiety or depression should be treated, and psychosocial issues should be addressed. 

Measure Exclusions

Denominator Exclusions:

• Persons in hospice or using hospice services any time during the measurement period.
• Persons receiving Palliative Care or had an encounter for Palliative Care any time during the intake period through the last day of the measurement period.
• Persons 66 years of age and older by the last day of the measurement period, with both frailty and advanced illness.
• Persons who died any time during the measurement period.
• Visits that result in an inpatient visit are not included.
• Persons with the following diagnoses or procedures that may warrant imaging any time during the person’s history through 28 days after the IESD:
  
  • Cancer, HIV, history of organ transplant, osteoporosis or spondylopathy.
  • Organ transplant, lumbar surgery or medication treatment for osteoporosis.
  • A dispensed prescription to treat osteoporosis.
• Persons with a recent diagnosis that may warrant imaging any time during the 365 days prior to the IESD through 28 days after the IESD.
  
  • IV drug abuse, neurologic impairment or spinal infection.
• Persons with a recent injury that may warrant imaging any time during the 90 days prior to the IESD through 28 days after the IESD.
  
  • Trauma or a fragility fracture.
• Persons with prolonged use of corticosteroids.
  
  • 90 consecutive days of corticosteroid treatment any time during the 366-day period that begins 365 days prior to the IESD and ends on the IESD.

Exclusion Codes

The exclusion codes are too numerous to list here. To obtain the complete set of codes associated with the LBP measure exclusions, please contact your Provider Engagement Liaison or email [email protected].

Exclusion value sets:
Cancer, HIV, history of organ transplant, osteoporosis or spondylopathy:

• Diagnosis History That May Warrant Imaging Value Set.

Organ transplant, lumbar surgery or medication treatment for osteoporosis: 

• Procedure History That May Warrant Imaging Value Set.

IV drug abuse, neurologic impairment or spinal infection:

• Recent Diagnoses That May Warrant Imaging Value Set.

Trauma or a fragility fracture: 

• Recent Injuries That May Warrant Imaging Value Set.

Exclusion Medications

Corticosteroid Medications

• Betamethasone-betamethasone acetate
• Cortisone
• Dexamethasone
• Hydrocortisone
  
• Methylprednisolone
• Prednisolone
• Prednisone
• Triamcinolone

Osteoporosis Medications

• Abaloparatide
• Alendronate
• Alendronate-cholecalciferol
• Denosumab
• Ibandronate
• Raloxifene
• Risedronate
• Romosozumab
• Teriparatide
• Zoledronic acid

Measure Codes

Principal diagnosis of uncomplicated low back pain in an outpatient setting.

• ICD-10-CM: M47.26, M47.27, M47.28, M47.816, M47.817, M47.818, M47.896, M47.897, M47.898, M48.061, M48.07, M48.08, M51.16, M51.17, M51.26, M51.27, M51.36, M51.360, M51.362, M51.369, M51.370, M51.372, M51.379 M51.37, M51.86, M51.87, M53.2X6, M53.2X7, M53.2X8, M53.3, M53.86, M53.87, M53.88, M54.16, M54.17, M54.18, M54.30, M54.31, M54.32, M54.40, M54.41, M54.42, M54.5, M54.50, M54.51, M54.59, M54.89, M54.9, M99.03, M99.04, M99.23, M99.33, M99.43, M99.53, M99.63, M99.73, M99.83, M99.84, S33.100A, S33.100D, S33.100S, S33.110A, S33.110D, S33.110S, S33.120A, S33.120D, S33.120S, S33.130A, S33.130D, S33.130S, S33.140A, S33.140D, S33.140S, S33.5XXA, S33.6XXA, S33.8XXA, S33.9XXA, S39.002A, S39.002D, S39.002S, S39.012A, S39.012D, S39.012S, S39.092A, S39.092D, S39.092S, S39.82XA, S39.82XD, S39.82XS, S39.92XA, S39.92XD, S39.92XS
• SNOMED CT US Edition: 2415007, 3200003, 12519004, 18347007, 20021007, 23056005, 26538006, 29885006, 38253002, 39058009, 46578006, 46960006, 48210000, 60937000, 61486003, 67437007, 79244005, 86345004, 86814006, 90631008, 91240008, 102831002, 111653006, 123798002, 128196005, 128197001, 129179000, 202487003, 202674000, 202675004, 202676003, 202677007, 202678002, 202679005, 202680008, 202693003, 202694009, 202695005, 202696006, 202708005*

Imaging Study

• CPT: 72020, 72040, 72050, 72052, 72070, 72072, 72074, 72080, 72081, 72082, 72083, 72084, 72100, 72110, 72114, 72120, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72200, 72202, 72220
• SNOMED CT US Edition: 22791004, 41333006, 60443006, 90523008, 91333005, 241580002, 241592002, 241646009, 241647000, 241648005, 429860003, 429868005, 429871002, 430021001, 430507007, 431250008, 431496002, 431557005, 431613003, 431871005, 431892005, 432078003, 432244001, 432770001, 433140006, 433141005, 440450002, 443580006, 444634007, 448641007, 700319007, 700320001, 700321002, 702487007, 702488002, 702513003, 702514009, 702515005, 702516006, 702521009, 702522002, 702523007, 702607002, 702608007, 709652000, 709653005, 709698004, 711104001, 711184004, 711186002, 711224009, 711271003, 712970008, 713016000, 715290001, 715458009, 716830000, 717912001, 718542005, 718545007, 723646000, 726546000, 772220000, 783627007, 840361000, 868279006, 1251643002, 1343368005, 3721000087104, 3731000087102, 14871000087107, 17141000087101, 58211000087104, 394451000119106, 396171000119100, 411571000119106, 411611000119102, 413001000119107, 495741000119105, 571891000119109, 572091000119106, 16328021000119109, 16384831000119100, 16554061000119109

*Please note that not all codes are listed here. For access to the complete set of codes related to  LBP measure, contact your Provider Engagement Liaison or email [email protected].