Federal Employee Program (FEP) Members
The preferred conservative medical treatment for uncomplicated low back pain (LBP) is prescription-strength analgesics and physical therapy. Evidence does not support routine imaging for uncomplicated LBP. Severe LBP improves for most individuals within the first two weeks of onset. Imaging when not indicated may expose members 
to unnecessary radiation and expense.1
Healthcare Effectiveness Data and Information Set (HEDIS®) Measures for 2020-212
One measure we collect for the National Committee for Quality Assurance (NCQA) evaluates the appropriate use of imaging studies for uncomplicated LBP.
This measure evaluates the percentage of members ages 18 to 50 diagnosed with LBP without the following.3
- Prior diagnosis of LBP in the past six months
- Imaging studies in the first 28 days (includes X-ray, MRI and CT scans) after diagnosis
Note: A higher percentage on this measure indicates better performance.
Associated Medical Conditions
Imaging within 28 days after diagnosis may be necessary if the member has other medical concerns. Examples of medical conditions that may require early imaging studies are listed in the chart below. Document the medical condition and appropriate code when able to show the need for early imaging studies. Doing so will not affect your HEDIS score.
Early Imaging Exclusions |
ICD-10 Codes |
|---|---|
Cancer (active) |
C00.0-96. Z and D00.00-49.9 |
Cancer (personal history) |
Z85-86.03 |
Corticosteroid Use (90 consecutive days) |
During 12 months prior to LBP diagnosis |
HIV |
B20; Z21 |
IV Drug Abuse |
F11.10-15.29 (any time during 12 months prior to LBP diagnosis) |
History of Kidney Transplant (Kidney Transplant) |
Z94.0; (0TY00Z0-2, 0TY10Z0-2) |
Organ Transplant Other Than Kidney |
02YA0Z0-2, 07YM0Z0-2, 07YP0Z0-2, 0BYC0Z0-2, 0BYD0Z0-2, 0BYF0Z0-2, 0BYG0Z0-2, 0BYH0Z0-2, 0BYJ0Z0-2, 0BYK0Z0-2, 0BYL0Z0-2, 0BYM0Z0-2, 0DY50Z0-2, 0DY60Z0-2, 0DY80Z0-2, 0DYE0Z0-2, 0FY00Z0-2, 0FYG0Z0-2, 0UY00Z0-2, 0UY10Z0-2, 0UY90Z0-2, 0WY20Z0-1, 0XYJ0Z0-1, 0XYK0Z0-1, 3E030U1, 3E033U1, 3E0J3U1, 3E0J7U1, 3E0J8U1 |
Neurologic Impairment |
G83.4 (any time during 12 months prior to LBP diagnosis) |
Spinal Infection, Osteomyelitis and Discitis |
A17.81, G06.1, M46.25-46.28, M46.35-46.38, M46.46-46.48 (any time during 12 months prior to LBP diagnosis) |
Trauma/Fractures |
G89.11; “S” series (any time during 3 months prior to LBP diagnosis) |
Whom can I contact with questions?
If you have questions regarding the use of the HEDIS LBP measure with your FEP members, please contact Dr. Sonja Hughes.
1 HEDIS measure for Use of Imaging Studies for Low Back Pain; accessed 7/7/2020
2 Measurement year 2020 and measurement year 2021
3 NCQA HEDIS Measurement Year 2020 & Measurement Year 2021 Technical specifications for health plans, volume 2, Washington DC, 2020
The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. Physicians and other health care providers are encouraged to use their own best medical judgment based upon all available information and the condition of the patient in determining the best course of treatment.
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