Low back pain (LBP) is common, affecting about 75 percent of Americans at some time in their lives. The preferred conservative treatment for uncomplicated LBP is prescription-strength analgesics and physical therapy, according to the American Association of Neurological Surgeons.
Evidence doesn’t support imaging for LBP within the first 28 days of diagnosis, according to the National Committee for Quality Assurance (NCQA). When not indicated, imaging may expose members unnecessarily to radiation and additional treatment. LBP improves for most people within two weeks of onset.
Supporting Quality Care
The Healthcare Effectiveness Data and Information Set (HEDIS®) from NCQA measures the appropriate use of diagnostic imaging studies, including X-rays, for LBP. We track data from HEDIS measures to help assess and improve our members’ care.
The LBP measure captures members ages 18 to 75 with a principal diagnosis of LBP who did not have an imaging study (plain X-ray, MRI, or CT scan) within 28 days of the LBP diagnosis in the following care settings:
- Office visits, outpatient evaluations, telemedicine/telehealth visits, emergency department visits, and observation level of care
- Physical therapy and/or osteopathic and/or chiropractic manipulative treatment
A higher score indicates better performance.
Exclusions for Other Medical Concerns
Imaging within 28 days of diagnosis may be necessary if a member has other medical conditions, such as:
- Recent trauma
- IV drug use
- Neurologic impairment
- Human immunodeficiency virus (HIV)
- Spinal infection
- Major organ transplant
- Prolonged use of corticosteroids
Document the condition and appropriate code, when applicable, to exclude a member with LBP from the HEDIS measure. See HEDIS Measures and Technical Resources for more details.
The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. The fact that a service or treatment is described in this material, is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.
HEDIS is a registered trademark of NCQA.