2017 MIPS Measure #361: Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry

Valid Data Submission Method(s) Measure Type High Priority Measure? NQS Domain Specialty Measure Sets
Registry Structure Yes Patient Safety Diagnostic Radiology

Measure Description

Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry that is capable of collecting at a minimum selected data elements

Instruction

This measure is to be reported each time a procedure for a CT imaging report is performed during the performance period. There is no diagnosis associated with this measure. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

Denominator

All final reports for patients, regardless of age, undergoing a CT procedure

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 registry-based measures.

Denominator Criteria (Eligible Cases):
All patients regardless of age
AND
Patient procedure during the performance period (CPT): 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 71250, 71260, 71270, 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, 77078, 78072, 78814, 78815, 78816, 0042T

Numerator

CT studies performed that are reported to a radiation dose index registry that is capable of collecting at a minimum all of the following data elements:

  • Manufacturer
  • Study description
  • Manufacturer’s model name
  • Patient’s weight
  • Patient’s size
  • Patient’s sex
  • Patient’s age
  • Exposure time
  • X-Ray tube current
  • Kilovoltage (kV)
  • Mean Volume Computed tomography dose index (CTDIvol)
  • Dose-length product (DLP)

Detailed information regarding the patient demographic and scanner data elements included in the Digital Imaging and Communication in Medicine (DICOM) header and CT irradiation event data elements included in the DICOM Supplement 127: CT Radiation Dose Reporting (Dose Structured Report) can be found in the Dose Index Registry Data Dictionary available on the American College of Radiology (ACR) Web site: Dose Index Registry Data Dictionary

Numerator Options:
Performance Met: CT studies performed reported to a radiation dose index registry that is capable of collecting at a minimum all necessary data elements (G9327)
OR
Performance Not Met: CT studies performed not reported to a radiation dose index registry that is capable of collecting at a minimum all necessary data elements, reason not given (G9326)

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