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

Eligible Population:
Members 18 –75 years as of December 31 of the measurement year.

Definition:
Percentage of members with a new primary diagnosis of uncomplicated low back pain in an outpatient setting who did not have an imaging study (plain X-ray, MRI or CT scan) within the first 4 weeks (28 days) of the primary diagnosis.

Age clarification: 18 to 75 years as of December 31 of the measurement year.

Report two age stratifications and a total rate:

• 18–64 
• 65–75
• Total * The total is the sum of the age stratifications

Intake Period: Identifies the first eligible encounter with a primary diagnosis of low back pain between January 1 - December 3 of the measurement year.

• Eligible encounter settings include:
  • Office visits, outpatient evaluations, emergency department visits, observation level of care, telephone visits, e-visits or virtual check-in visits
  • Osteopathic and/or chiropractic manipulative treatment or physical therapy.

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.

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

• NOTE: Members are excluded who have a positive diagnosis history during this timeframe.

Continuous Enrollment:

• 180 days prior to the IESD through 28 days after 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

Required Exclusion:

• Members in hospice or using hospice services anytime during the measurement year.
• Palliative Care
• Frailty and Advanced Illness
• Members who died any time during the measurement year.
• Measure exclusions identify members for whom imaging may be clinically appropriate within the first 4 weeks.
• Visits that result in an inpatient visit are not included.

Members with a diagnosis where imaging is clinically appropriate will be excluded.  Timeframes for each are noted.

• Any time during the member’s history through 28 days after the IESD: 
  • Cancer:  ICD-10 C and D Codes (active) / Z Codes (history of)- Examples include:
    • Malignant Neoplasms ICD-10-CM: C00.0-C00.6, C00.8, C00.9, C01, C02.0-C02.4, C02.8, C02.9, C03.0, C03.1, C03.9, C04.0, C04.1, C04.8, C04.9, C05.0, C05.1, C05.2, C05.8, C05.9, C06.0, C06.1, C06.2, C06.80, C06.89, C06.9, C07, C08.0, C08.1, C08.9, C09.0, C09.1, C09.8, C09.9, C10.0- C10.4, C10.8, C10.9, C11.0-C11.3, C11.8, C11.9, C12, C13.0, C13.1, C13.2, C13.8, C13.9, C14.0, C14.2, C14.8, C15.3, C15.4, C15.5, C15.8, C15.9, C16.0-C16.6, C16.8, C16.9, C17.0-C17.3, C17.8, C17.9, C18.0-C18.9, C19, C20, C21.0; C92.60, C93.92, C93.Z0, C93.Z1, C93.Z2, C94.00, C94.01, C94.02, C94.20, C94.21, C94.22, C94.30, C94.31, C94.32, C94.40, C94.41, C94.42, C94.6, C94.80, C94.81, C94.82, C95.00, C95.01, C95.02, C95.10, C95.11, C95.12, C95.90, C95.91, C95.92 C96.0, C96.2, C96.20, C96.21, C96.22, C96.29, C96.4, C96.5, C96.6, C96.9, C96.A, C96.Z; 
      • Additional codes apply.
  • Other Neoplasms ICD-10-CM: D00.00- D00.08, D00.1, D00.2, D01.0- D01.3, D01.40, D01.49, D01.5, D01.7, D01.9, D02.0, D02.1, D02.20-D02.22, D02.3, D02.4, D03.0, D03.10, D03.11, D03.111, D03.112, D03.121, D03.122, D03.20, D03.21, D03.22, D03.30, D03.39, D03.4, D03.51, D03.52, D03.59, D03.60, D03.61, D03.62, D03.70, D03.71, D03.72, D03.8, D03.9, D04.0, D04.10, D04.11, D04.111, D04.112, D04.12, D04.121, D04.122, D04.20, D04.21, D04.22, D04.30, D04.39, D04.4, D04.5, D04.60, D04.61, D04.62, D04.70, D04.71, D04.72, D04.8, D04.9, D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.90, D05.91, D05.92, D06.0, D06.1, D06.7, D06.9, D07.0, D07.1, D07.2, D07.30, D07.39, D07.4, D07.5, D07.60, D07.61, D07.69, D09.0, D09.10, D09.19, D09.20, D09.21, D09.22, D09.3, D09.8, D09.9, D37.01, D37.02, D37.030, D37.031, D37.032, D37.039, D37.04, D37.05, D37.09, D37.1- D37.6, D37.8, D37.9, D38.0-D38.6, D39.0, D39.10, D39.11, D39.12, D39.2, D39.8, D39.9, D40.0, D40.10, D40.11, D40.12, D40.8, D40.9, D41.00, D41.01, D41.02, D41.10, D41.11, D41.12, D41.20, D41.21, D41.22, D41.3, D41.4, D41.8, D41.9, D42.0, D42.1, D42.9, D43.0-D43.4, D43.8, D43.9, D44.0, D44.10, D44.11, D44.12, D44.2-D44.7, D44.9, D45, D46.0, D46.1, D46.20, D46.21, D46.22, D46.4, D46.9, D46.A, D46.B, D46.C, D46.Z, D47.0, D47.01, D47.02, D47.09-D47.4, D47.9, D47.Z1, D47.Z2, D47.Z9, D48.0-D48.5, D48.60, D48.61, D48.62, D48.7, D48.9, D49.0, D49.1, D49.2, D49.3, D49.4, D49.5, D49.511, D49.512, D49.519, D49.59, D49.6, D49.7, D49.81, D49.89, D49.9
  • History of Malignant Neoplasm ICD-10-CM: Z85.00, Z85.01, Z85.020, 
  • Other Malignant Neoplasm of Skin ICD-10-CM: C44.00-C44.02
• HIV ICD-10-CM: B20, Z21
• Kidney / Major organ transplant
  • History of Kidney Transplant ICD-10-CM:  Z94.0
  • Kidney Transplant: 
    • CPT: 50360, 50365, 50380, 
    • HCPCS: S2065
    • ICD-10-PCS: 0TY00Z0, 0TY00Z1, 0TY00Z2, 0TY10Z0, 0TY10Z1, 0TY10Z2
  • Organ Transplant Other Than Kidney: 
    • CPT : 32850, 32851, 32852, 32853, 32854, 32855, 32856
• Osteoporosis
  • Osteoporosis therapy or a dispensed prescription to treat osteoporosis
    • HCPCS: J0897, J1740, J3110, J3111, J3489

Osteoporosis Medications

• Lumbar surgery
  • CPT: 22114, 22207, 22214, 22224, 22511, 22512, 22514, 22515, 22533, 22534, 22558, 22612, 22630, 22632, 22633, 22634, 22857, 22860, 22862, 22865, 22867, 22868, 22869, 22870, 62287, 62380, 63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047, 63048, 63052, 63053, 63056, 63057, 63087, 63088, 63090, 63091, 63102, 63103, 63170, 63200, 63252, 63267, 63272, 63277, 63282, 63287
  • HCPCS: S2348, S2350
  • ICD-10-PCS Examples: 
    • [005Y0ZZ] Destruction of Lumbar Spinal Cord, Open Approach
    • [008Y0ZZ] Division of Lumbar Spinal Cord, Open Approach
    • [009Y00Z] Drainage of Lumbar Spinal Cord with Drainage Device, Open Approach
    • [00BY0ZX] Excision of Lumbar Spinal Cord, Open Approach, Diagnostic
    • [00CY0ZZ] Extirpation of Matter from Lumbar Spinal Cord, Open Approach
    • [00NY0ZZ] Release Lumbar Spinal Cord, Open Approach
    • [00QY0ZZ] Repair Lumbar Spinal Cord, Open Approach
    • [00SY0ZZ] Reposition Lumbar Spinal Cord, Open Approach
    • [0Q500ZZ] Destruction of Lumbar Vertebra, Open Approach
    • [0Q800ZZ] Division of Lumbar Vertebra, Open Approach
    • [0QH004Z] Insertion of Internal Fixation Device into Lumbar Vertebra, Open Approach
    • [0QR03KZ] Replacement of Lumbar Vertebra with Nonautologous Tissue Substitute, Percutaneous Approach
    • [0QU007Z] Supplement Lumbar Vertebra with Autologous Tissue Substitute, Open Approach
    • [0SG037J] Fusion of Lumbar Vertebral Joint with Autologous Tissue Substitute, Posterior Approach, Anterior Column, Percutaneous Approach
    • [0SW4XKZ] Revision of Nonautologous Tissue Substitute in Lumbosacral Disc, External Approach
    • Additional codes apply. 
  • Spondylopathy ICD-10-CM: M45.0, M45.3, M45.4, M45.5, M45.6, M45.7, M45.8, M45.9, M48.10, M48.13, M48.14, M48.15, M48.16, M48.17, M48.18, M48.19
• Any time during the 12 months (1 year) prior to the IESD through 28 days after the IESD:
  • Neurologic impairment ICD-10-CM: G83.4, K59.2, M48.062, R26.2, R29.2
  • Spinal infection ICD-10-CM: A17.81, G06.1, M46.25-M46.28, M46.35-M46.38, M46.46-M46.48
  • Intravenous drug abuse ICD-10-CM:  F11.10, F11.11, F11.120- F11.122, F11.129, F11.13, F11.14, F11.150, F11.151, F11.159, F11.181, F11.182, F11.188, F11.19, F11.20, F11.21, F11.220, F11.221, F11.222, F11.229, F11.23, F11.24, F11.250, F11.251, F11.259, F11.281, F11.282, F11.288, F11.29, F13.10, F13.11, F13.120, F13.121, F13.129, F13.130, F13.131, F13.132, F13.139, F13.14, F13.150, F13.151, F13.159, F13.180, F13.181, F13.182, F13.188, F13.19, F13.20, F13.21, F13.220, F13.221, F13.229, F13.230, F13.231, F13.232, F13.239, F13.24, F13.250, F13.251, F13.259, F13.26, F13.27, F13.280, F13.281, F13.282, F13.288, F13.29, F14.10, F14.11, F14.120, F14.121, F14.122, F14.129, F14.13, F14.14, F14.150, F14.151, F14.159, F14.180, F14.181, F14.182, F14.188, F14.19, F14.20, F14.21, F14.220, F14.221, F14.222, F14.229, F14.23, F14.24, F14.250, F14.251, F14.259, F14.280, F14.281, F14.282, F14.288, F14.29, F15.10, F15.11, F15.120, F15.121, F15.122, F15.129, F15.13, F15.14, F15.150, F15.151, F15.159, F15.180, F15.181, F15.182, F15.188, F15.19, F15.20, F15.21, F15.220, F15.221, F15.222, F15.229, F15.23, F15.24, F15.250, F15.251, F15.259, F15.280, F15.281, F15.282, F15.288, F15.29
• Any time during the 3 months (90 days) prior to the IESD through 28 days after the IESD:
  • Recent trauma ICD-10-CM: G89.11 and  S codes for trauma/fractures
  • Fragility fracture ICD-10-CM: M48.40XA, M48.40XD, M48.40XG, M48.40XS, M48.41XA, M48.41XD, M48.41XG, M48.41XS, M48.42XA, M48.42XD, M48.42XG, M48.42XS, M48.43XA, M48.43XD, M48.43XG, M48.43XS, M48.44XA, M48.44XD, M48.44XG, M48.44XS, M48.45XA, M48.45XD, M48.45XG, M48.45XS, M48.46XA, M48.46XD, M48.46XG, M48.46XS, M48.47XA, M48.47XD, M48.47XG, M48.47XS, M48.48XA, M48.48XD, M48.48XG, M48.48XS, M80.08XA, M80.08XD, M80.08XG, M80.08XK, M80.08XP, M80.08XS, M80.88XA, M80.88XD, M80.88XG, M80.88XK, M80.88XP, M80.88XS, M84.359A, M84.359D, M84.359G, M84.359K, M84.359P, M84.359S, M97.01XA, M97.01XD, M97.01XS, M97.02XA, M97.02XD, M97.02XS
• Any time during the 366-day period that begins 365 days prior to the IESD and ends on the IESD, where there is 90 consecutive days of corticosteroid treatment:
  • Prolonged use of corticosteroids.
    • When identifying consecutive treatment days, do not count days’ supply that extend beyond the IESD. For example, if a member had a 90-day prescription dispensed on the IESD, there is one covered calendar day (the IESD).   

Corticosteroid Medications

Measure Codes

• Principal diagnosis of uncomplicated low back pain in an outpatient setting.
  • Uncomplicated Low Back Pain 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, M51.37, 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  

Avoid the below Imaging Study Codes during the first 30 days of a diagnosis of uncomplicated back pain.

• 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