2023 # 436 Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques

CMS Measure ID: #436

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: No

High Priority: No

NQS Domain: Effective Clinical Care

Measure Age: > 2 years

Instructions

This measure is to be submitted each time a patient has a computed tomography scan during the performance period. There is no diagnosis associated with this measure. It is anticipated that eligible clinicians who provide the professional component of diagnostic imaging studies for computed tomography 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

Percentage of final reports for patients aged 18 years and older undergoing computed tomography (CT) with documentation that one or more of the following dose reduction techniques were used:

  • Automated exposure control
  • Adjustment of the mA and/or kV according to patient size
  • Use of iterative reconstruction technique

2022 Benchmarks (from 2020 CMS data)

Registry

Topped out: Yes
Capped at 7: Yes

Minimum: 0 – 99.48
Decile 3: 99.49 – 99.88
Decile 4: 99.89 – 99.98
Decile 5: 99.99 – 99.99
Decile 10: 100 – 100

Denominator

All final reports for patients aged 18 years and older undergoing CT

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):
Patients aged ≥ 18 years on date of encounter

AND

Patient procedure during the performance period (CPT or HCPCS): 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 71250, 71260, 71270, 71271, 71275, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72191, 72192, 72193, 72194, 73200, 73201, 73202, 73206, 73700, 73701, 73702, 73706, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178,74261, 74262, 74263*, 75571, 75572, 75573, 75574, 75635, 76380, 76497, 77011, 77012, 77013, 77014, 77078, 0042T

WITHOUT

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

Numerator

Final reports with documentation that indicate an individualized dose optimization technique was used for the performed procedure. Dose optimization techniques include the following:

  • Automated exposure control
  • Adjustment of the mA and/or kV according to patient size
  • Use of iterative reconstruction technique

Numerator Note: Per exam/report: An individualized exposure protocol/optimization technique per scanner can be included in the report using a macro associated with the exam or procedure.

Attestation: Alternatively, a general attestation statement in the final report can suffice to meet the measure; however there should be a written policy in place describing the process that ensures dose optimization techniques are used appropriately per instrument/room, as well as a method for validating that their use occurs for each patient, e.g. periodic audits.

Example statement:

All CT scans at “location” are performed using dose optimization techniques as appropriate to a performed exam including the following:

  • Automated exposure control
  • Adjustment of the mA and/or kV according to patient size (this includes techniques or standardized protocols for targeted exams where dose is matched to indication / reason for exam; i.e. extremities or head)
  • Use of iterative reconstruction technique

Numerator Options:

Performance Met:

Final reports with documentation of one or more dose reduction techniques (e.g., Automated exposure control, adjustment of the mA and/or kV according to patient size, use of iterative reconstruction technique) (G9637)

OR

Performance Not Met:

Final reports without documentation of one or more dose reduction techniques (e.g., Automated exposure control, adjustment of the mA and/or kV according to patient size, use of iterative reconstruction technique) (G9638)


Tags

CQM-2023