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2021 MIPS Measure #145: Radiology: Exposure Dose Indices or Exposure Time and Number of Images 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 Merit-based Incentive Payment System (MIPS) eligible clinicians providing the services for procedures using fluoroscopy will submit this measure.

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 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 MIPS CQMs.

Denominator Criteria (Eligible Cases):

Patient encounter during the performance period (CPT or HCPCS): 0075T, 0202T, 0234T, 0235T, 0236T, 0237T, 0238T, 0338T, 0339T, 22526*, 25606, 25651, 26608, 26650, 26676, 26706, 26727, 27235, 27244, 27245, 27509, 27756, 27759, 28406, 28436, 28456, 28476, 34703, 34704, 34705, 34706, 34718, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 36100, 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, 37248, 43260, 43261, 43262, 43263, 43264, 43265, 43274, 43275, 43276, 43277, 43278, 43752, 47537, 49440, 49441, 49442, 49446, 49450, 49451, 49452, 49460, 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, 74221 74235, 74240, 74246, 74251, 74270, 74280, 74283, 74290, 74300, 74328, 74329, 74330, 74340, 74355, 74360, 74363, 74425, 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, 76080, 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*

 

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)

Numerator Instructions:

Documentation: Information populating the final report may reside in a dedicated field in the electronic health record (EHR) or picture archiving and communication system (PACS), however fluoroscopy exposure dose or time should be included in the final report in order to be readily accessible in all circumstances.

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, report 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)

 

Rationale

Increasing physician awareness of patient exposure to radiation is an important step towards reducing the potentially harmful effects of radiation as a result of imaging studies. One study by Darling et al found a significant correlation between documentation of fluoroscopy time by the radiologist in the dictated radiology report and reduced overall fluoroscopy time. Additional studies demonstrate that providing physicians with feedback regarding their fluoroscopy time leads to a reduction in average fluoroscopy times.

 

Clinical Recommendation Statements

All available radiation dose data should be recorded in the patient’s medical record. If cumulative air kerma or air kerma- area-product data are not available, the fluoroscopic exposure time and the number of acquired images (radiography, cine, or digital subtraction angiography) should be recorded in the patient’s medical record. (ACR, 2013)

For the present, and for the purpose of this guideline, adequate recording of dose metrics is defined as documentation in the patient record of at least one of the following for all interventional procedures requiring fluoroscopy (in descending order of desirability): skin dose mapping, PSD, Ka,r, PKA, and fluoroscopic time/number of fluorographic images. Note, however, that this is adequate recording; this document recommends recording of all available dose metrics. (SIR, 2012)

[ACR] should now encourage practices to record actual fluoroscopy time for all fluoroscopic procedures. The fluoroscopy time for various procedures (e.g., upper gastrointestinal, pediatric voiding cystourethrography, diagnostic angiography) should then be compared with benchmark figures. More complete patient radiation dose data should be recorded for all high-dose interventional procedures, such as embolizations, transjugular intrahepatic portosystemic shunts, and arterial angioplasty or stent placement anywhere in the abdomen and pelvis. (Amis et al., ACR, 2007)

Measure & record patient radiation dose:
• Record fluoroscopy time
• Record available measures - DAP (dose area product), cumulative dose, skin dose (NCI, 2005)

PKA, also known as kerma-area product (KAP) or dose-area product (DAP), is the integral of air kerma (the energy extracted from an x-ray beam per unit mass of air in a small irradiated air volume; for diagnostic x-rays, the dose delivered to that volume of air) across the entire x-ray beam emitted from the x-ray tube. It is a surrogate measure of the amount of energy delivered to the patient, and thus a reasonable indicator of the risk of stochastic effects. The symbol PKA is the notation recommended by the International Commission on Radiation Units and Measurements (ICRU, 2012).

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