2023 # 145 Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy

CMS Measure ID: #145

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: No

High Priority: Yes

NQS Domain: Patient Safety

Measure Age: > 2 years

Instructions

This measure is to be submitted each time a procedure using fluoroscopy is performed in a hospital or outpatient setting during the performance period. There is no diagnosis associated with this measure. It is anticipated that eligible clinicians providing the services for procedures using fluoroscopy will submit this measure.

Measure Submission Type:

The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted for registry submissions; however, these codes may be submitted for those registries that utilize claims data.

Description

Final reports for procedures using fluoroscopy that document radiation exposure indices

2022 Benchmarks (from 2020 CMS data)

Registry

Topped out: Yes
Capped at 7: Yes

Minimum: 0 – 94.1
Decile 3: 94.11 – 99.08
Decile 4: 99.09 – 99.97
Decile 5: 99.98 – 99.99
Decile 10: 100 – 100

Denominator

All final reports for procedures using fluoroscopy

DENOMINATOR NOTE: The final report of the fluoroscopy procedure or fluoroscopy guided procedure includes the final radiology report, definitive operative report, or other definitive procedure report that is communicated to the referring physician, primary care physician, follow-up care team, and/or maintained in the medical record of the performing physician outside the EHR or other medical record of the facility in which the procedure is performed.

*Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases):

Patient encounter during the performance period (CPT or HCPCS): 0075T, 0202T, 0234T, 0235T, 0236T, 0237T, 0238T, 0338T, 0339T, 22526*, 25606, 25651, 26608, 26650, 26676, 26706, 26727, 27235, 27244, 27245, 27509, 27756, 27759, 28406, 28436, 28456, 28476, 33477, 33741, 33745, 33897, 33900, 33901, 33902, 33903, 34703, 34704, 34705, 34706, 34718, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 36221, 36222, 36223, 36224, 36225, 36226, 36251, 36252, 36253, 36254, 36598, 36901, 36902, 36903, 36904, 36905, 36906, 37182, 37183, 37184, 37187, 37188, 37211, 37212, 37213, 37214, 37215, 37216*, 37217, 37218, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37236, 37238, 37241, 37242, 37243, 37244, 37246, 37248, 43260, 43261, 43262, 43263, 43264, 43265, 43274, 43275, 43276, 43277, 43278, 43752, 47537, 49440, 49441, 49442, 49446, 49450, 49451, 49452, 49460, 50382, 50384, 50385, 50386, 50387, 50389, 61623, 61630, 61635, 61640*, 61645, 61650, 62263, 62264, 62280, 62281, 62282, 62302, 62303, 62304, 62305, 70010, 70015, 70170, 70332, 70370, 70371, 70390, 72240, 72255, 72265, 72270, 72285, 72295, 73040, 73085, 73115, 73525, 73580, 73615, 74210, 74220, 74221, 74235, 74240, 74246, 74251, 74270, 74280, 74300, 74328, 74329, 74330, 74340, 74355, 74360, 74363, 74425, 74440, 74445, 74450, 74470, 74485, 74742, 75600, 75605, 75625, 75630, 75705, 75710, 75716, 75726, 75731, 75733, 75736, 75741, 75743, 75746, 75756, 75801, 75803, 75805, 75807, 75810, 75825, 75827, 75831, 75833, 75840, 75842, 75860, 75870, 75872, 75880, 75885, 75887, 75889, 75891, 75893, 75894, 75898, 75901, 75902, 75956, 75957, 75958, 75959, 75970, 76000, 76080, 76496, 77001, 77002, 77003, 92611, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93503, 93505, 93580, 93581, 93593, 93594, 93595, 93596, 93597, 93583, G0106, G0120, G0122*

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02

Numerator

Final reports for procedures using fluoroscopy that include radiation exposure indices

Numerator Instructions:

Documentation: Dose information in the final report may be located in a variety of sources and should be available to the referring physician on receipt of report.

Definition:

Radiation exposure indices – For the purposes of this measure, radiation exposure indices should, if possible, include at least one of the following:

  1. Reference air kerma (Ka,r ) in Gy or mGy
  2. Kerma-area product (PKA ) or Dose area product (DAP) in uGy*m², mGy*cm² (or similar)
  3. Peak skin dose (PSD) in Gy or mGy

When reporting indices the report must clearly state what radiation quantity is being submitted, that is only reporting dose in mGy is insufficient. PSD in mGy is very different from Ka,r in mGy. As an example, PSD = 10 mGy or Ka,r = 10 mGy would meet numerator performance, but “10 mGy” alone would not.

Note: When reporting reference air kerma or kerma-area product for biplane systems, the value should be reported as the sum of both planes (or the value for each plane should be reported individually).

NUMERATOR NOTE: In interventional radiology procedures with runs, dose indices are displayed on the console and in the radiation dose structured report (RDSR).

Numerator Options:

Performance Met: Radiation exposure indices documented in final report for procedure using fluoroscopy (G9500)

OR

Performance Not Met: Radiation exposure indices not documented in final report for procedure using fluoroscopy, reason not given (G9501)


Tags

CQM-2023