2026 #364 MIPS Measure Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines

2026 COLLECTION TYPE:

MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)

‌MEASURE TYPE:

Process – High Priority

‌DESCRIPTION:

Percentage of final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older that contain an impression or conclusion that includes a recommended interval and modality for follow-up (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians).

‌INSTRUCTIONS:

‌Reporting Frequency:

This measure is to be submitted each time a denominator eligible procedure as defined in the denominator criteria is performed.

Intent and Clinical Applicability:

This measure is intended to reflect the quality of surgical services provided for patients aged 35 years and older that underwent CT imaging studies. There is no diagnosis associated with this measure. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions as defined by the numerator based on the services provided and the measure-specific denominator coding.

Measure Strata and Performance Rates:

This measure contains one strata defined by a single submission criteria. The measure produces a single performance rate.

Implementation Consideration:

For the purposes of MIPS implementation, this procedure measure is submitted each time a procedure is performed during the performance period.

Telehealth:

NOT TELEHEALTH ELIGIBLE: This measure is not appropriate for nor applicable to the telehealth setting. This measure is procedure based and therefore doesn’t allow for the denominator criteria to be conducted via telehealth. It would be appropriate to remove these patients from the denominator eligible patient population. Telehealth eligibility is at the measure level for inclusion within the denominator eligible patient population and based on the measure specification definitions which are independent of changes to coding and/or billing practices.

‌Measure Submission:

The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this collection type for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. The coding provided to identify the measure criteria: Denominator or Numerator, may be an example of coding that could be used to identify patients that meet the intent of this clinical topic. When implementing this measure, please refer to the ‘Reference Coding’ section to determine if other codes or code languages that meet the intent of the criteria may also be used within the medical record to identify and/or assess patients. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

‌DENOMINATOR:

All final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older.

Definition:

Heavy Tobacco Smokers – Patients who are “heavy tobacco smokers” includes patients with a 30 pack-year tobacco smoking history and currently smoke tobacco or have quit within the past 15 years. This definition is consistent with the USPSTF recommendation for lung cancer screening.

DENOMINATOR NOTE:

CT imaging studies include all studies in which all or part of the thorax can be seen.

Granulomas, hamartomas or lesions with internal fat, or other characteristically benign findings are not considered incidental findings in the context or intent of this measure. Therefore, they are not included in the measure denominator. However, generally accepted radiology practices should be followed with respect to communication and management of these characteristically benign findings.

Denominator Criteria (Eligible Cases):

All patients age 35 years and older

AND

Patient procedure during the performance period (CPT): 70490, 70491, 70492, 75571, 75572, 75573, 75574, 70498, 71250, 71260, 71270, 71275, 72125, 72126, 72127, 72128, 72129, 72130, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178

AND

A finding of an incidental pulmonary nodule: G9754

AND NOT

DENOMINATOR EXCLUSIONS:

Patients with an active diagnosis or history of cancer (except basal cell and squamous cell skin carcinoma), patients who are heavy tobacco smokers, lung cancer screening patients: M1018

‌NUMERATOR:

Final reports that contain an impression or conclusion that includes a recommended interval and modality for follow-up (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians).

Definition:

Follow-up Recommendations – No follow-up recommended in the final CT report OR follow-up is recommended within a designated time frame in the final CT report. Recommendations noted in the final CT report should be in accordance with recommended guidelines.

Numerator Options:

Performance Met: Follow-up recommendations documented according to recommended guidelines for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors (G9345)

OR

Denominator Exception: Documentation of medical reason(s) for not including a recommended interval and modality for follow-up or for no follow-up, and source of recommendations (e.g., patients with unexplained fever, immunocompromised patients who are at risk for infection) (G9755)

OR

Performance Not Met: Follow-up recommendations not documented according to recommended guidelines for incidentally detected pulmonary nodules, reason not given (G9347)

RATIONALE:

With the increasing use of chest computed tomography (CT) imaging comes an increase in the frequency of incidental pulmonary nodule findings. (MacMahon, et al., 2017)

A recent study found that between 2006 and 2012, the annual rate of pulmonary nodule identification in a large, integrated health system increased from 3.9 to 6.6 per 1,000 person-years. The authors estimated that more than 1.5 million adult Americans will have a pulmonary nodule identified each year. (MacMahon et al., 2017)

These incidental findings require appropriate management to avoid subjecting patients to unnecessary follow-up scans or conversely missing early malignancies. A number of factors contribute to appropriate management decisions for pulmonary nodules, based on estimations of the individual risk of malignancy including nodule size and morphology as well as clinical risk factors. (MacMahon et al., 2017)

Despite evidence-based recommendations from groups such as the Fleishner society regarding the management and follow-up of small pulmonary nodules detected incidentally, various studies have documented low rates of adherence. For example, one recent study found that 44.7% of patients received care inconsistent with the Fleischner society recommendations (17.8% overevaluation, 26.9% underevaluation). (MacMahon et al., 2017)

This measure aims to encourage the use of an evidence-based approach in recommending follow up imaging for incidental pulmonary nodules.