| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Process | Yes | Communication and Care Coordination | Diagnostic Radiology |
Measure Description
Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution’s computer systems
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 imaging reports with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution’s computer systems
Numerator Instructions: Standardized nomenclature is used in institution’s computer systems, including but not limited:
- Computerized physician ordering system
- Charge master
- Radiology information system
- Electronic health record
NUMERATOR NOTE: Use of a standardized nomenclature is meant to enable reporting to a Dose Index Registry. There is no standard lexicon implemented across the board for naming CT exam procedures. To make like comparisons of sites reporting dose index data to a registry, it is necessary to use a specific CT exam name and standardize that across registry participants.
An example of a standardized nomenclature is RadLex®. Other standardized nomenclature may be available and would be acceptable for this measure. RadLex® is a controlled terminology for radiology—a single unified source of radiology terms that is designed to fill this need. The purpose of RadLex® is to provide a uniform structure for capturing, indexing, and retrieving a variety of radiology information sources, such as teaching files and research data. This may facilitate a first step toward structured reporting of radiology reports. This will also permit mining of data for participation in research projects, registries, patient outcomes and quality assurance.
Numerator Options:
Performance Met: Imaging study named according to standardized nomenclature (G9318)
OR
Performance Not Met: Imaging study not named according to standardized nomenclature, reason not given (G9319)