Physicians/Specialists
Facilities/Hospitals
Publication Date: 
2021-08-12

August 12, 2021: This communication has been reposted as a further resource and reminder to providers. The update was originally posted on November 16, 2020.


To help providers ensure members are receiving the most appropriate care to effectively manage symptoms of Low Back Pain (LBP) and to improve Healthcare Effectiveness Data and Information Set (HEDIS) scores for this measure, HEDIS Quality Measure guidelines for LBP are listed below. Providers need to make certain that they are submitting claims correctly and adhering to the guidelines outlined in the LBP HEDIS chart. 

Key Points  

  • After complaint of back ache from a member, providers should utilize more conservative therapy measures for pain management first. Providers should wait at least 29 days before ordering imaging. 
  • Based on Blue Cross and Blue Shield of North Carolina (Blue Cross NC) data, a high percentage of our members with a diagnosis of LBP are undergoing imaging within 28 days of diagnosis, which is outside of HEDIS guidelines. 
  • These guidelines apply to fully insured, Administrative Services Only (ASO), State Health Plan, Inter-Plan Program Host (IPP Host) and FEP members. 

HEDIS Quality Measure for LBP 

Rather than immediately ordering imaging, follow the LBP HEDIS chart below for more conservative measures.  Additionally, you can also refer to the Choosing Wisely for Back Pain report or Choosing Wisely guideline from the American Academy of Family Physicians as educational resources to share with members.   

HEDIS Quality Measure 

Clinical Goal 

Criteria to Meet Goal 

 

LBP Administrative measure 

 

Use of Imaging Studies for Low Back Pain 

 

The percentage of members with a primary diagnosis of low back pain who did NOT have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.  

 

The Intake period is 1/1/ to 12/3 each year. 

Members 18 to 50 years will NOT receive imaging studies within 28 days of the initial diagnosis of low back pain. 

 

This includes a plain X-ray 

 

Consider more conservative measures such as referral for physical therapy evaluation before X-rays are ordered. 

Claims: 

  • Submit a claim with a code for low back pain with first symptoms of low back pain. 
  • Submit a claim with code for exclusion if appropriate  
    • Per NCQA HEDIS exclusion specifications - any member who had a diagnosis for which imaging is clinically appropriate. Any of the following meet criteria: 
      • Malignant Neoplasm 
      • History of Malignant Neoplasm 
      • HIV 
      • Prolonged Use of Corticosteroids 
      • Other Neoplasms 
      • IV Drug Use 
      • Recent Trauma  
      • Major Organ Transplant 
      • Spinal Infection in previous year   

Medical record documentation not applicable  

 

 

If you have questions, please contact Sharon Gee Brown at Sharon.GeeBrown@bcbsnc.com