2017 MIPS Measure #363: Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive

Valid Data Submission Method(s) Measure Type High Priority Measure? NQS Domain Specialty Measure Sets
Registry Structure Yes Communication and Care Coordination Diagnostic Radiology

Measure Description

Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media-free, shared archive prior to an imaging study being performed

Instruction

This measure is to be reported each time a procedure for a computed tomography (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.

This measure is intended for reporting by facilities that can search for available images/image data from non-affiliated external healthcare facilities.

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

Final reports of CT studies, which document that a search for DICOM format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media-free, shared archive prior to an imaging study being performed

Definition:
Media-free – Radiology images that are transmitted electronically ONLY, not images recorded on film, CD, or other imaging transmittal form.

Numerator Options:
Performance Met: Search conducted for prior patient CT studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media-free, shared archive prior to an imaging study being performed (G9341)
OR
Denominator Exception: Due to system reasons search not conducted for DICOM format images for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12 months that are available through a secure, authorized, media-free, shared archive (e.g., non-affiliated external healthcare facilities or entities does not have archival abilities through a shared archival system) (G9344)
OR
Denominator Exception: Documentation of medical reason for not conducting a search for DICOM format images for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12 months that are available through a secure, authorized, media-free, shared archive (e.g., trauma, acute myocardial infarction, stroke, aortic aneurysm where time is of the essence) (G9753)
OR
Performance Not Met: Search not conducted prior to an imaging study being performed for prior patient CT studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media-free, shared archive, reason not given (G9342)

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