#145: Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy

Quality ID

145

High Priority Measure

Yes

Specifications

Registry

Measure Type

Process

Specialty

Diagnostic Radiology Interventional Radiology

Measure description

Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available)

 

Instructions

This measure is to be submitted each time fluoroscopy is performed in a hospital or outpatient setting during the performance period. There is no diagnosis associated with this measure. It is anticipated that eligible clinicians providing the services for procedures using fluoroscopy will submit this measure.

Measure Submission:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions 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.

 

Denominator

All final reports for procedures using fluoroscopy

DENOMINATOR NOTE: The final report of the fluoroscopy procedure or fluoroscopy guided procedure includes the final radiology report, definitive operative report, or other definitive procedure report that is communicated to the referring physician, primary care physician, follow-up care team, and/or maintained in the medical record of the performing physician outside the EHR or other medical record of the facility in which the procedure is performed.

*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 registrybased measures.

Denominator Criteria (Eligible Cases):

Patient encounter during the performance period (CPT or HCPCS): 0075T, 0202T, 0234T, 0235T, 0236T, 0237T, 0238T, 0254T,0338T, 0339T, 22526*, 25606, 25651, 26608, 26650, 26676, 26706, 26727, 27235, 27244, 27245, 27509, 27756, 27759, 28406, 28436, 28456, 28476, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 36221, 36222, 36223, 36224, 36225, 36226, 36251, 36252, 36253, 36254, 36598, 36901, 36902, 36903, 36904, 36905, 36906, 37182, 37183, 37184, 37187, 37188, 37211, 37212, 37213, 37214, 37215, 37216*, 37217, 37218, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37236, 37238, 37241, 37242, 37243, 37244, 37246, 37247, 37248, 37249, 43260, 43261, 43262, 43263, 43264, 43265, 43274, 43275, 43276, 43277, 43278, 43752, 47537, 49440, 49441, 49442, 49446, 49450, 49451, 49452, 49460, 49465, 50382, 50384, 50385, 50386, 50387, 50389, 50590, 61623, 61630, 61635, 61640*, 61645, 61650, 62263, 62264, 62280, 62281, 62282, 62302, 62303, 62304, 62305, 64610, 70010, 70015, 70170, 70332, 70370, 70371, 70390, 72240, 72255, 72265, 72270, 72275, 72285, 72295, 73040, 73085, 73115, 73525, 73580, 73615, 74190, 74210, 74220, 74230, 74235, 74240, 74241, 74245, 74246, 74247, 74249, 74251, 74260, 74270, 74280, 74283, 74290, 74300, 74328, 74329, 74330, 74340, 74355, 74360, 74363, 74425, 74430, 74440, 74445, 74450, 74455, 74470, 74485, 74740, 74742, 75600, 75605, 75625, 75630, 75705, 75710, 75716, 75726, 75731, 75733, 75736, 75741, 75743, 75746, 75756, 75801, 75803, 75805, 75807, 75810, 75820, 75822, 75825, 75827, 75831, 75833, 75840, 75842, 75860, 75870, 75872, 75880, 75885, 75887, 75889, 75891, 75893, 75894, 75898, 75901, 75902, 75956, 75957, 75958, 75959, 75970, 76000, 76001, 76080, 76120, 76496, 77001, 77002, 77003, 92611, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93503, 93505, 93530, 93531, 93532, 93533, 93580, 93581, 93583, G0106, G0120, G0122* G0278

 

Numerator

Final reports for procedures using fluoroscopy that include radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available)

Definition:

Radiation exposure indices - For the purposes of this measure, radiation exposure indices should, if possible, include at least one of the following:

1. Skin dose mapping

2. Peak skin dose (PSD)

3. Reference air kerma (Ka,r)

4. Kerma-area product (PKA ) or Dose area product (DAP)

When reporting indices the report must clearly state what radiation quantity is being submitted, that is only reporting dose in mGy is insufficient. PSD in mGy is very different from Ka,r in mGy. As an example, PSD = 10 mGy or Ka,r = 10 mGy.

If the fluoroscopic equipment does not automatically provide any of the above radiation exposure indices, exposure time and the number of fluorographic images taken during the procedure may be used.

NUMERATOR NOTE: In interventional radiology procedures with runs, dose indices are displayed on the console and in the radiation dose structured report (RDSR). For instruments without dose indicator measurement capability, submit the overall fluoroscopic time and the number of runs done where additional exposure (fluoroscopic or x-ray) occurs.

“Last image hold” is part of the fluoroscopic exam and would be included in the total fluoroscopic time. No additional radiation is involved, so the image would not be counted.

Count images where the patient received or potentially received any exposure, fluorographic or radiographic (x-ray).

Numerator Options:

Performance Met: Radiation exposure indices, OR exposure time and number of fluorographic images in final report for procedures using fluoroscopy, documented (G9500)

OR

Performance Not Met: Radiation exposure indices, OR exposure time and number of fluorographic images not documented in final report for procedure using fluoroscopy, reason not given (G9501)

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