Imaging for Uncomplicated Low Back Pain

Each year, approximately 2.5 million Americans visit an outpatient clinical setting for low back pain (LBP). It is estimated that 75% of adults will experience low back pain at some time in their lives.

Evidence has shown that unnecessary or routine imaging (X-ray, MRI, CT scans) for low back pain is NOT associated with improved outcomes. This exposes patients to unnecessary harms, such as radiation and unneeded treatment. Most individuals who experience low back pain will improve within the first two weeks of onset. Avoiding imaging for patients when there is no indication of underlying conditions can prevent unnecessary harm and reduce health care costs.1

HEDIS Measure

Healthcare Effectiveness Data and Information Set (HEDIS®) quality measure Use of Imaging for Low Back Pain (LBP) evaluates adults ages 18-75 with a principal ICD-10 diagnosis of uncomplicated LBP* who did not receive imaging studies (plain X-ray, MRI, or CT scan) within 28 days of diagnosis.

The care settings include outpatient evaluations, telemedicine/telehealth, emergency department, observation level of care, physical therapy, and osteopathic/chiropractic manipulative treatment.

Noncompliance occurs when an imaging study is performed for uncomplicated LBP within 28 days of initial diagnosis.

Exclusions

The following conditions are not considered uncomplicated and would exclude the member from the LBP measure. Imaging within 28 days would be acceptable for the following conditions (this is not a complete list):

  • Discitis, unspecified, lumbar region
  • Discitis, unspecified, lumbosacral region
  • Muscle spasm of back
  • Contusion of lower back
  • Unspecified superficial injury of lower back

Recognizing that each patient is unique, National Committee of Quality Assurance (NCQA) has identified exclusions for medical conditions that may require imaging within 28 days of initial diagnosis. If any of these conditions exist, include diagnosis on your submitted claim.2

  • Cancer or members in hospice/palliative care
  • Recent trauma/fractures (anytime during three months prior to diagnosis)
  • IV drug abuse (12 months prior)
  • Neurologic impairment (12 months prior)
  • Human immunodeficiency virus (HIV)
  • Spinal infection (12 months prior)
  • Kidney/major organ transplant
  • Prolonged use of corticosteroids (90 consecutive days of treatment within 12 months prior)
  • Osteoporosis medication therapy
  • History of lumbar surgeries
  • Spondylopathy
  • Recent history uncomplicated low back pain (six months prior)

(Note: This list is not all-inclusive. This information is not about a change in policy, but a reference to quality improvement activities).

How to Improve HEDIS Scores

  • Avoid ordering diagnostic studies (x-rays, CT, or MRI Scans) within 28 days of diagnosis for a new onset of uncomplicated LBP in the absence of an excluded medical condition.
  • Document in medical record all findings and use correct coding. Use exclusionary codes if applicable (as noted above) to justify if imaging is warranted.
  • Provide patient education on conservative treatments. Recommendations include:
    • Use of non-steroidal anti-inflammatory drugs (NSAIDS) and, if appropriate, muscle relaxers.
    • Exercise to strengthen the core and low back.
    • Move and be active to limit muscle stiffening.
    • Place pillow while resting or sleeping between legs if sleeping on side or under knees when sleeping on back to reduce back discomfort.

Please refer to John Hopkins HealthCare LLC’s “LBP – Use of Imaging Studies for Low Back Pain” for additional information: Use of Imaging Studies for Low Back Pain (hopkinsmedicine.org) .

Additional Resources

The Provider Resource Center (PRC) has the following educational materials, which can be accessed by going to the PRC, selecting EDUCATION/MANUALS from the left menu, and clicking Educational Resources – Member And Provider:

  • Back Pain Brochure
  • Back Pain Post Card
  • Back Pain Poster

References

Highmark does not recommend particular treatments or health care services. This information is not intended to be a substitute for professional medical advice, diagnosis, or treatment. You should determine the appropriate treatment and follow-up with your patient. Coverage of services is subject to the terms of each member’s benefit plan. Additionally, state laws and regulations governing health insurance, health plans and coverage may apply and will vary from state to state.

1NCQA HEDIS Measures and Technical Resources: https://www.ncqa.org/hedis/measures/use-of-imaging-studies-for-low-back-pain .

2Information taken from HEDIS MY 2023 Volume 2: Technical Specifications.

*(ICD-10 Uncomplicated Low Back Pain Codes: M47.26-M47.898; M48.061-M48.08; M51.16-M51.87; M53.2X6-M53.88; M54.16-M54.9; M99.03-M99.84; S33.100A-S33.9XXA; S39.002A-S39.92XS)

The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of NCQA.

 

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