Measure Description
Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are submitted to a radiation dose index registry that is capable of collecting at a minimum selected data elements
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 Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
Measure Submission Type:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
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 MIPS CQMs.
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, 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: https://www.acr.org/Practice-Management-Quality-Informatics/Registries/Dose-Index-Registry
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)