Aug. 12, 2022: This communication has been updated to change the clinical goal age range from 18-50 to 18-75.

Jul. 7, 2022: This communication has been updated to include additional details regarding the clinical goal and criteria to meet the goal. 

Aug. 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 guidelines below for more conservative measures. Additionally, you can also refer to the Choosing Wisely guideline from the American Academy of Family Physicians as educational resources to share with members.   

HEDIS QUALITY MEASURE 

• 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. 

CLINICAL GOAL 

• Members 18 to 75 years will NOT receive imaging studies within 28 days of the initial diagnosis of low back pain. 
• This includes a plain X-ray. 
• Consider referral for physical therapy evaluation before X-rays are ordered. 

CRITERIA TO MEET GOAL 

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 exclusion criteria:
  • Cancer
  • Recent Trauma
  • IV Drug Abuse
  • Neurologic Impairment
  • HIV
  • Spinal Infection
  • Major Organ Transplant
  • Prolonged Use of Corticosteroids
  • Osteoporosis
  • Fragility Fracture
  • Lumbar Surgery
  • Spondylopathy
  • Palliative Care
  • Hospice
  • Frailty and Advanced Illness (must have both; applies to members 66 years of age and older)
• Medical record documentation not applicable 

If you have questions, please email Sharon Gee Brown.