June 2019

Guidelines for Imaging in Low Back Pain

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Healthcare Effectiveness Data and Information Set (HEDIS^®) was developed and is maintained by the National Committee for Quality Assurance (NCQA) to standardize and measure quality for all patients. The Office of Personnel Management (OPM) reviews HEDIS performance of certain measures for Federal Employee Program^® (FEP^®) members. One of these measures looks at the appropriate use of all diagnostic imaging studies, including x-rays, for uncomplicated new onset lower back pain. Generally, patients with new onset low back pain diagnosis should not receive any imaging within the first 28 days of diagnosis, but rather receive conservative medical treatment with prescription strength analgesics and physical therapy.

NCQA realizes that each patient’s presentation is unique, and imaging may be required, and has therefore added a vast number of medical conditions where imaging could be considered medically necessary on initial patient presentation. Providing the additional diagnosis in your medical evaluation when such situations present exclude such patients from your HEDIS metric.

For information purposes only, the chart below outlines some such additional diagnoses that may present during a low back pain patient visit.

DESCRIPTION	ICD-10 CODE
Cancer (active)	All ICD-10 “C” codes
Cancer (personal history)	All ICD-10 “Z” codes
HIV	B20; Z21
IV drug abuse	All ICD-10 “F” codes
Kidney transplant	0TY00Z0-0TY00Z2; 0TY10Z0-0TY10Z2
Major organ transplant, other than kidney	Heart, small intestine, large intestine, liver, pancreas islets, ovaries, face, head, thymus, spleen, lungs, esophagus, stomach
Neurologic impairment	G83.4
Spinal infection, osteomyelitis, and discitis	A17.81, G06.1, M46.25-M46.28, M46.35-M46.38, M46.46-M46.48
Trauma/fractures	All ICD-10 “S” codes

Note: The above list is not all inclusive.

If you have any questions regarding the HEDIS measure for Use of Imaging in Low Back Pain, visit ncqa.org.

HEDIS is a registered trademark of NCQA.

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.