2023 # 419 Overuse of Imaging for the Evaluation of Primary Headache

CMS Measure ID: #419

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: No

High Priority: Yes

NQS Domain: Efficiency and Cost Reduction

Measure Age: > 2 years

Instructions

This measure is to be submitted at each denominator eligible visit for patients with a diagnosis of primary headache during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

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

Percentage of patients for whom imaging of the head (CT or MRI) is obtained for the evaluation of primary headache when clinical indications are not present

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: Yes
Capped at 7: No

Decile 0: 68.05 – 100
Decile 1: 37.83 – 68.04
Minimum: 16.49 – 37.82
Decile 3: 8.87 – 16.48
Decile 4: 6.22 – 8.86
Decile 5: 2.99 – 6.21
Decile 6: 0.6 – 2.98
Decile 7: 0.01 – 0.59
Decile 10: 0 – 0

Denominator

All patients seen for evaluation of primary headache

Definition:
Change in headache – A significant change in severity of the headache including changes in location or quality. Other criteria take into account most red flag symptoms and also may reflect change (if a stable primary headache were previously present) but do not reflect a previously tolerated headache that now becomes suddenly disabling in severity. Change also includes any and all new symptoms that may be associated with a headache: arm numbness, speech disturbance, etc.

DENOMINATOR NOTE: *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):

All patients, regardless of age

AND

Diagnosis for Primary Headache (ICD-10-CM): G43.001, G43.009, G43.011, G43.019, G43.101, G43.109, G43.111, G43.119, G43.401, G43.409, G43.411, G43.501, G43.509, G43.511, G43.519, G43.601, G43.609, G43.611, G43.619, G43.701, G43.709, G43.711, G43.719, G43.801, G43.809, G43.811, G43.819, G43.821, G43.829, G43.831, G43.839, G43.901, G43.909, G43.911, G43.919, G44.019, G44.029, G44.039, G44.1, G44.209, G44.219, G44.221, G44.229, G44.52, G44.59, G44.81, G44.82, G44.89, R51.0, R51.9, G44.009, G44.049, G44.059, G44.099, G44.51, G44.53, G44.83, G44.84, G44.85

AND

Patient encounter during the performance period (CPT): 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*

AND NOT

DENOMINATOR EXCLUSION:

Patients with clinical indications for imaging of the head:

Head trauma: G2187
New or change in headache above 50 years of age: G2188
Abnormal neurologic exam: G2189
Headache radiating to the neck: G2190
Positional headaches: G2191
Temporal headaches in patients over 55 years of age: G2192
New onset headache in pre-school children or younger (<6 years of age): G2193
New onset headache in pediatric patients with disabilities for which headache is a concern as inferred from behavior: G2194
Occipital headache in children: G2195
Thunderclap headache: G44.53
Trigeminal pain: G50.0
Persistent headaches: G44.52

Numerator

Patients for whom imaging of the head (Computed Tomography (CT) or Magnetic Resonance Imaging (MRI)) is obtained for the evaluation of primary headache when clinical indications are not present

Numerator Instruction: INVERSE MEASURE – A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

Numerator Options:

Performance Met:

Imaging of the head (CT or MRI) was obtained (M1027)

Denominator Exception:

Documentation of patients with primary headache diagnosis and imaging other than CT or MRI obtained (M1028)

Denominator Exception:

Imaging needed as part of a clinical trial; or other clinician ordered the study (G9537)

Performance Not Met:

Imaging of the head (CT or MRI) was NOT obtained, Reason not given (M1029)