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