#359: Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description

Quality ID

359

High Priority Measure

Yes

Specifications

Registry

Measure Type

Process

Specialty

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

 

Instructions

This measure is to be submitted 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 submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

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 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, 77014, 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® Playbook. Other standardized nomenclature may be available and would be acceptable for this measure. RadLex® Playbook provides a standardized method for radiology procedure naming based on exam characteristics such as modality and body part. The purpose ofRadLex® Playbook 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)

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