Measure Description
Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury.
Instructions
This measure is to be submitted for each denominator eligible visit for patients aged 2 through 17 years who present to the emergency department with a minor blunt head trauma during the performance period. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who provide care in the emergency department 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 emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider*
Definitions:
Minor Blunt Head Trauma – Includes only non-penetrating injuries.
DENOMINATOR NOTE: *This measure looks to determine if an emergency care provider ordered head CT services typically provided under CPT code 70450.
Denominator Criteria (Eligible Cases):
Patients aged 2 through 17 years on date of encounter
AND
Diagnosis for minor blunt head trauma (ICD-10-CM): S00.03XA, S00.33XA, S00.431A, S00.432A, S00.439A, S00.531A, S00.532A, S00.83XA, S00.93XA, S06.A0XA, S06.A1XA, S06.0XAA, S06.0X0A, S06.0X1A, S06.0X9A, S06.1XAA, S06.1X0A, S06.1X1A, S06.1X2A, S06.1X3A, S06.1X4A, S06.1X9A, S06.2XAA, S06.2X0A, S06.2X1A, S06.2X2A, S06.2X3A, S06.2X4A, S06.2X9A, S06.30AA, S06.300A, S06.301A, S06.302A, S06.303A, S06.304A, S06.309A, S06.31AA, S06.32AA, S06.33AA, S06.34AA, S06.340A, S06.341A, S06.342A, S06.343A, S06.344A, S06.349A, S06.35AA, S06.350A, S06.351A, S06.352A, S06.353A, S06.354A, S06.359A, S06.36AA, S06.360A, S06.361A, S06.362A, S06.363A, S06.364A, S06.369A, S06.37AA, S06.38AA, S06.4XAA, S06.4X0A, S06.4X1A, S06.4X2A, S06.4X3A, S06.4X4A, S06.4X9A, S06.5XAA, S06.5X0A, S06.5X1A, S06.5X2A, S06.5X3A, S06.5X4A, S06.5X9A, S06.6XAA, S06.6X0A, S06.6X1A, S06.6X2A, S06.6X3A, S06.6X4A, S06.6X9A, S06.81AA, S06.810A, S06.811A, S06.812A, S06.813A, S06.814A, S06.819A, S06.82AA, S06.820A, S06.821A, S06.822A, S06.823A, S06.824A, S06.829A, S06.89AA, S06.890A, S06.891A, S06.892A, S06.893A, S06.894A, S06.899A, S06.9XAA, S06.9X0A, S06.9X1A, S06.9X2A, S06.9X3A, S06.9X4A, S06.9X9A, S09.11XA, S09.19XA, S09.8XXA
AND
Patient encounter during the performance period (CPT): 99281, 99282, 99283, 99284, 99285, 99291
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10
AND
Patient presented with a minor blunt head trauma and had a head CT ordered for trauma by an emergency care provider: G9594
AND NOT
DENOMINATOR EXCLUSION:
Patient has documentation of ventricular shunt, brain tumor, or coagulopathy: G9595
Numerator
Emergency department visits for patients who are classified as low risk according to the PECARN prediction rules for traumatic brain injury
Definition:
Low Risk for Traumatic Brain Injury according to PECARN prediction rules –
Patients can be classified as low risk if ALL of the following are met:
- No signs of altered mental status (e.g., agitation, somnolence, repetitive questioning, slow response to verbal communication) OR no GCS < 15
- No signs of basilar skull fracture (signs include haemotympanum, “raccoon” eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
- No loss of consciousness
- No vomiting
- No severe mechanism of injury (i.e., motor vehicle crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle; falls of more than 5 feet; or head struck by a high-impact object)
- No severe headache
Numerator Instructions:
INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.
Numerator Options:
Performance Met: Pediatric patient with minor blunt head trauma classified as low risk according to the PECARN prediction rules (G9593)
OR
Performance Met: Pediatric patient with minor blunt head trauma and PECARN prediction criteria are not assessed (G0047)
OR
Performance Not Met: Pediatric patient with minor blunt head trauma not classified as low risk according to the PECARN prediction rules (G9597)
Rationale
Though it is difficult to directly attribute the effects of smaller dosages of radiation, there is evidence to suggest that the low dose radiation emitted through the use of some CT scans is associated with a small, but cumulative risk of radiation-induced cancer, particularly in children (Frush et al., 2003). As over 1.3 million individuals are treated and released from the ED for mild traumatic brain injury annually, it is critical that CT scans only be utilized when clinically appropriate (Melnick et al., 2012). Through measurement of the share of CT scans that are performed inappropriately, a focus can be brought to quality improvement and increased application of clinical decision tools around this topic.
This measure is an overuse measure - its intention is to capture those instances in which a pediatric patient is characterized as low risk yet still receives a CT. As such, the measure is scored such that a lower score indicates better quality. The measure is constructed in this manner due to the available evidence; the PECARN clinical policy defines the low-risk population, but does not clearly define the medium and high risk populations. The measure then uses the definable population as its numerator, necessitating an "overuse" construction.
Clinical Recommendation Statements
The following evidence statements are quoted verbatim from the referenced clinical guidelines and other references:
[ADAPTED] Suggested CT algorithm for children aged 2 years and older with GCS scores of 14-15 after head trauma (PECARN, 2009):
If GCS=14 or other signs of altered mental status or signs of basilar skull fracture, then CT recommended.
If no GCS=14 nor other signs of altered mental status nor signs of basilar skull fracture and no history of LOC, nor history of vomiting, nor severe mechanism of injury nor severe headache, then CT not recommended.
If no GCS=14 nor other signs of altered mental status nor signs of basilar skull fracture AND If History of LOC, or history of vomiting, or severe mechanism of injury or severe headache, then observation versus CT on the basis of other clinical factors including:
- Physician experience
- Multiple versus isolated findings
- Worsening symptoms or signs after ED observation
- Parental preference
For a visual decision rule aid that describes the prediction rule, visit https://www.aliem.com/2017/06/pecarn-pediatrichead-trauma-official-visual-decision-aid/.
1.4.9 For children who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:
- Suspicion of non-accidental injury.
- Post-traumatic seizure but no history of epilepsy.
- On initial emergency department assessment, GCS less than 14.
- At 2 hours after the injury, GCS less than 15.
- Suspected open or depressed skull fracture or tense fontanelle.
- Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign).
- Focal neurological deficit. (NICE, 2014)
1.4.10 For children who have sustained a head injury and have more than 1 of the following risk factors (and none of those in recommendation 1.4.9), perform a CT head scan within 1 hour of the risk factors being identified:
- Loss of consciousness lasting more than 5 minutes (witnessed).
- Abnormal drowsiness.
- Three or more discrete episodes of vomiting.
- Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 meters, high-speed injury from a projectile or other object).
- Amnesia (antegrade or retrograde) lasting more than 5 minutes. (NICE, 2014)
1.4.11 Children who have sustained a head injury and have only 1 of the risk factors in recommendation 1.4.10 (and none of those in recommendation 1.4.9) should be observed for a minimum of 4 hours after the head injury. If during observation any of the risk factors below are identified, perform a CT head scan within 1 hour:
- GCS less than 15.
- Further vomiting.
- A further episode of abnormal drowsiness. (NICE, 2014)