OP-8: MRI LUMBAR SPINE FOR LOW BACK PAIN

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Rafe King
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1 Description of Measure OP-8: MRI LUMBAR SPINE FOR LOW BACK PAIN This measure calculates the percentage of MRI of the Lumbar Spine studies with a diagnosis of low back pain on the imaging claim and for which the patient did not have prior claims-based evidence of antecedent conservative therapy. Antecedent conservative therapy may include (see subsequent details for codes): 1. Claim(s) for physical therapy in the 60 days preceding the Lumbar Spine MRI. 2. Claim(s) for chiropractic evaluation and manipulative treatment in the 60 days preceding the Lumbar Spine MRI. 3. Claim(s) for evaluation and management in the period >28 days and <60 days preceding the Lumbar Spine MRI. Numerator Statement MRI of the lumbar spine studies with a diagnosis of low back pain (from the denominator) without the patient having claims-based evidence of prior antecedent conservative therapy. Technical Note: The numerator measurement of prior conservative therapy is based on the claim date of the MRI of the lumbar spine from the denominator, with the prior conservative therapy within the defined time periods relative to each MRI lumbar spine claim (i.e., a patient can be included in the numerator count more than once, if the patient had more than one MRI lumbar spine procedure in the measurement period and the MRI lumbar spine procedure occurred on different days). Denominator Statement MRI of the lumbar spine studies with a diagnosis of low back pain on the imaging claim. Technical Notes: 1. The diagnosis of low back pain must be on the MRI lumbar spine claim (i.e., the lumbar spine MRI must be billed with a low back pain diagnosis in one of the diagnoses fields on the claim). MRI lumbar spine studies without a diagnosis of low back pain on the claim are not included in the denominator count. 2. If a patient had more than one MRI lumbar spine study for a diagnosis of low back pain on the same day only one study would be counted, but if a patient had multiple MRI lumbar spine studies with a diagnosis of low back pain on the claim during the measurement period each study would be counted (i.e., a patient can be included in the denominator count more than once). 1 Revised April 2014

2 Numerator Codes CPT Codes: MRI Lumbar Spine without Contrast MRI Lumbar Spine with Contrast MRI Lumbar Spine with and without Contrast Indications of claims based antecedent conservative therapy include any procedure codes in the three following groups: Claim(s) for physical therapy with the following CPT codes in the 60 days preceding the Lumbar Spine MRI: Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercise to develop strength and endurance, range of motion and flexibility Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Aquatic therapy with therapeutic exercises Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) Manual therapy technical (e.g. mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes Claim(s) for chiropractic evaluation and manipulative treatment with the following CPT codes in the 60 days preceding the Lumbar Spine MRI: Chiropractic manipulative treatment (CMT); spinal, one to two regions Spinal, three to four regions Spinal, five regions Extraspinal, one or more regions Claim(s) for evaluation and management with the following CPT codes >28 days and <60 days preceding the Lumbar Spine MRI: Revised April 2014

3 Denominator Codes CPT Codes MRI Lumbar Spine without Contrast MRI Lumbar Spine with Contrast MRI Lumbar Spine with and without Contrast ICD-9 codes Lumbosacral spondylosis without myelopathy Spondylosis of unspecified site without mention of myelopathy Displacement of lumbar intervertebral disc without myelopathy Degeneration of lumbar or lumbosacral intervertebral disc Degeneration of intervertebral disc, site unspecified Other unspecified disc disorder of lumbar region Spinal stenosis of lumbar region Lumbago Sciatica Unspecified backache Disorders of sacrum Unspecified disorder of coccyx Hypermobility of coccyx Other disorder of the coccyx Other acquired deformity of back or spine Nonallopathic lesion of lumbar region, not elsewhere classified Nonallopathic lesion of sacral regions, not elsewhere classified Sprain and strain of lumbosacral (joint) (ligament) Sprain and strain of sacroiliac (ligament) Sprain and strain of sacrospinatus (ligament) Sprain and strain of sacrotuberous (ligament) Other specified sites of sacroiliac region sprain and strain Unspecified site of sacroiliac region sprain and strain Lumbar sprain and strain Denominator Exclusion Codes Indications for measure exclusion include any patients with the following procedures or diagnosis codes: Patients with lumbar spine surgery in the 90 days prior to MRI: CPT codes: and Cancer (Within twelve months prior to MRI procedure. A cancer exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: , , Revised April 2014

4 Congenital Spine and Spinal Cord Malformations (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: 741, 742.5X, 742.8, 742.9, 754.2, 756.1X, 759.7, , Inflammatory and Autoimmune Disorders (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: 323.6X, 323.8X, 323.9, 340, 341, 357.0, 696.0, 701.0, 710, 714, , Infectious Conditions (Within one year prior to MRI procedure. An exclusion ICD-9 codes: 013.1X, 013.4X, 013.5X, 013.6X, 015.0X, 094, , , , , , Spinal Vascular Malformations and/or the Cause of Occult Subarachnoid Hemorrhage (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: , , 430, , 442.9, 447.0, Spinal Cord Infarction (Within one year prior to MRI procedure. An exclusion ICD-9 codes: 336.1, Neoplastic Abnormalities (Within five years prior to MRI procedure. An exclusion ICD-9 codes: 198.3, 213.2, 213.6, 225.3, 225.4, 225.9, Treatment Fields for Radiation Therapy (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: 990 Spinal Abnormalities Associated with Scoliosis (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: 737, 756.5X Syringohydromyelia (Within five years prior to MRI procedure. An exclusion ICD-9 code: Revised April 2014

5 Postoperative Fluid Collections and Soft Tissue Changes (Within one year prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: , , Trauma: (Within 45 days prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: , , , , , , 929, 952, IV Drug Abuse: (Within twelve months prior to MRI procedure. An exclusion ICD-9 codes: 304.0X, 304.1X, 304.2X, 304.4X, 305.4X, 305.5X, 305.6X, 305.7X Neurologic Impairment: (Within twelve months prior to MRI procedure. An exclusion ICD-9 codes: , , Human Immunodeficiency Virus (HIV): (Within twelve months prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 codes: 042 Unspecified Immune Deficiencies: (Within twelve months prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-9 code: Intraspinal abscess: (An exclusion diagnosis must be in one of the diagnoses fields on the MRI lumbar spine claim.) ICD-9 codes: 324.1, Technical Note: If the diagnosis code is a three-digit ICD-9 code, then all codes starting with the three digits are used in the measure calculation, that is, all inclusive. If the diagnosis code is specified as a four-digit ICD-9 code, then only the specific four-digit diagnosis code is used. If the diagnosis code is a five-digit code, the code used is either the specific five-digit diagnosis code if all five numeric digits are shown, or if the fifth digit is designated with an x then this is designating an all inclusive range to the fifth digit. 5 Revised April 2014

6 OP-8: MRI LUMBAR SPINE FOR LOW BACK PAIN ICD-10 DRAFT SPECIFICATIONS Description of Measure This measure calculates the percentage of MRI of the Lumbar Spine studies with a diagnosis of low back pain on the imaging claim and for which the patient did not have prior claims-based evidence of antecedent conservative therapy. Antecedent conservative therapy may include (see subsequent details for codes): 1. Claim(s) for physical therapy in the 60 days preceding the Lumbar Spine MRI. 2. Claim(s) for chiropractic evaluation and manipulative treatment in the 60 days preceding the Lumbar Spine MRI. 3. Claim(s) for evaluation and management in the period >28 days and <60 days preceding the Lumbar Spine MRI. Numerator Statement MRI of the lumbar spine studies with a diagnosis of low back pain (from the denominator) without the patient having claims-based evidence of prior antecedent conservative therapy. Technical Note: The numerator measurement of prior conservative therapy is based on the claim date of the MRI of the lumbar spine from the denominator, with the prior conservative therapy within the defined time periods relative to each MRI lumbar spine claim (i.e., a patient can be included in the numerator count more than once, if the patient had more than one MRI lumbar spine procedure in the measurement period and the MRI lumbar spine procedure occurred on different days). Denominator Statement MRI of the lumbar spine studies with a diagnosis of low back pain on the imaging claim. Technical Notes: 1. The diagnosis of low back pain must be on the MRI lumbar spine claim (i.e., the lumbar spine MRI must be billed with a low back pain diagnosis in one of the diagnoses fields on the claim). MRI lumbar spine studies without a diagnosis of low back pain on the claim are not included in the denominator count. 2. If a patient had more than one MRI lumbar spine study for a diagnosis of low back pain on the same day only one study would be counted, but if a patient had multiple MRI lumbar spine studies with a diagnosis of low back pain on the claim during the measurement period each study would be counted (i.e., a patient can be included in the denominator count more than once). 6 Revised April 2014

7 Numerator Codes CPT Codes MRI Lumbar Spine without Contrast MRI Lumbar Spine with Contrast MRI Lumbar Spine with and without Contrast Indications of claims based antecedent conservative therapy include any procedure codes in the three following groups: Claim(s) for physical therapy with the following CPT codes in the 60 days preceding the Lumbar Spine MRI: Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercise to develop strength and endurance, range of motion and flexibility Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Aquatic therapy with therapeutic exercises Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) Manual therapy technical (e.g. mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes Claim(s) for chiropractic evaluation and manipulative treatment with the following CPT codes in the 60 days preceding the Lumbar Spine MRI: Chiropractic manipulative treatment (CMT); spinal, one to two regions Spinal, three to four regions Spinal, five regions Extraspinal, one or more regions Claim(s) for evaluation and management with the following CPT codes >28 days and <60 days preceding the Lumbar Spine MRI: Revised April 2014

8 Denominator Codes CPT Codes: MRI Lumbar Spine without Contrast MRI Lumbar Spine with Contrast MRI Lumbar Spine with and without Contrast ICD-10 codes Other deforming dorsopathies: M43.20, M43.25-M43.28, M43.5X5-M43.5X9, M43.8X5-M43.8X9, M43.9 Spondylopathies: M46.46-M46.47, M47.20, M47.26-M47.28, M M47.819, M M47.9, M48.06-M48.07 Other dorsopathies: M51.26-M51.27, M51.34-M51.37, M51.86-M51.87, M53.2X7-M53.2X8, M53.3, M53.86-M53.88, M54.30-M54.32, M54.40-M54.42, M54.5, M54.89, M54.9 Biomechanical lesion, not elsewhere classified: M99.03-M99.04, M99.23, M99.33, M99.43, M99.53, M99.63, M99.73, M99.83-M99.84 Dislocation and sprain of joints and ligaments of lumbar spine and pelvis: S33.5XX*-S33.9XX* Denominator Exclusion Codes Indications for measure exclusion include any patients with the following procedures or diagnosis codes: Patients with lumbar spine surgery in the 90 days prior to MRI: CPT codes: and Cancer (Within twelve months prior to MRI procedure. A cancer exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 codes: C00.0-C14.8, C15.3-C26.9, C30.0-C39.9, C40.0-C41.9, C43.0-C43.9, C44.00-C44.99, C45.0-C49.9, C C50.929, C51.0-C58, C60.1-C63.9, C64.1- C68.9, C69.00-C72.9, C73-C75.9, C76.0-C80.2, C81.00-C86.6, C88.2-C93.Z1, C93.90-C96.4, C96.A-C96.9, D00.00-D09.9, D37.01-D47.1, D47.3, D47.Z1-D48.9, D49.0-D49.9, Q85.00-Q85.09 Congenital Spine and Spinal Cord Malformations (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 codes: G90.1, Q05.0- Q07.03, Q07.8-Q07.9, Q67.5, Q76.0-Q76.419, Q Q76.429, Q76.49, Q79.8-Q79.9, Q87.2-Q87.3, Q87.5-Q87.89, Q89.7-Q Revised April 2014

9 Inflammatory and Autoimmune Disorders (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 codes: G04.00-G04.02, G04.30-G04.31, G04.39-G04.91, G05.4, G35-G37.9, G61.0, L40.50-L40.59, L90.0, L94.0-L94.1, L94.3, M05.00-M08.99, M M12.09, M32.0-M32.9, M33.00-M33.99, M34.0-M34.9, M35.0-M35.1, M35.5, M35.8-M35.9, M36.0, M36.8, Q79.6, Q87.40 Infectious Conditions (Within one year prior to MRI procedure. An exclusion ICD-10 codes: A17.1-A17.83, A18.01, A52.10-A52.17, A52.19, A52.2-A52.3, M46.20-M46.39, M86.08, M86.18, M86.28, M86.38, M86.48, M86.58, M86.68, M86.8X8, M86.9, M90.88 Spinal Vascular Malformations and/or the Cause of Occult Subarachnoid Hemorrhage (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 codes: D18.00, D18.09, I60.00-I60.9, I72.8-I72.9, I77.0, Q27.9 Spinal Cord Infarction (Within one year prior to MRI procedure. An exclusion ICD-10 codes: G95.11, G95.19, G96.9 Neoplastic Abnormalities (Within five years prior to MRI procedure. An exclusion ICD-10 codes: C79.31, D16.6, D16.8, D32.1, D33.4, D33.9, Q06.0-Q06.1, Q06.3, Q06.8 Treatment Fields for Radiation Therapy (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 code: T66.XXXA Spinal Abnormalities Associated with Scoliosis (Within five years prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 codes: M40.00, M40.05, M40.10, M40.15, M40.205, M40.209, M40.295, M40.299, M40.35-M40.37, M40.40, M40.45-M40.47, M40.50, M40.55-M40.57, M41.00, M41.05-M41.07, M M41.117, M M41.127, M41.20, M M41.27, M41.30, M41.35, M41.40, M41.45-M41.47, M41.50, M41.55-M41.57, M41.80, M41.85-M41.87, M41.9, M43.8X9, M96.2-M96.5, Q77.6, Q78.0-Q78.3, Q78.5-Q78.9 Syringohydromyelia (Within five years prior to MRI procedure. An exclusion ICD-10 code: G Revised April 2014

10 Postoperative Fluid Collections and Soft Tissue Changes (Within one year prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 codes: T81.89X*, T81.9XX*, T88.8XX* Trauma: (Within 45 days prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 codes: M48.40X*-M48.58X*, M67.90, M84.30X*-M84.38X*, M84.40X*- M84.48X*, M84.50X*-M84.58X*, M84.60X*-M84.68X*, M99.10-M99.19, S00.00X*-S09.93X*, S10.0XX*-S19.9XX*, S20.00X*-S29.9XX*, S30.0XX* - S32.811*, S32.89X -S39.94X*, S40.011*-S49.92X*, S50.00X*-S59.919*, S60.00X*-S69.92X*, S70.00X*-S79.929*, S80.00X*-S89.92X*, S90.00X*- S99.929*, T07, T14.8-T14.91, T15.00X*-T15.92X*, T16.1XX*-T17.998*, T18.0XX*-T18.9XX*, T19.0XX*-T19.9XX*, T20.00X*-T20.79X*, T21.00X*- T21.79X*, T22.00X*-T22.099*, T22.10X*-T22.199*, T22.20X*-T22.299*, T22.30X*-T22.399*, T22.40X*-T22.499*, T22.50X*-T22.599*, T22.60X*- T22.699*, T22.70X*-T22.799*, T23.001*-T23.099*, T23.101*-T23.199*, T23.201*- T23.299*, T23.301*-T23-399*, T23.401*-T23.499*, T23.501*-T23.599*, T23.601*- T23.699*, T23.701*-T23.799*, T24.001*-T24.099*, T24.101*-T24.199*, T24.201*- T24.299*, T24.301*-T24.399*, T24.401*-T24.499*, T24.501*-T24.599*, T24.601*- T24.699*, T24.701*-T24.799*, T25.011*-T25.799*, T26.00X*-T26.92X*, T27.0XX*-T27.7XX*, T28.00X*-T28.99X*, T33.011*-T33.99X*, T34.011*- T34.99X*, T36.0X1*-T36.0X5*, T36.1X1*-T36.1X5*, T36.2X1*-T36.2X5*, T36.3X1*-T36.3X5*, T36.4X1*-T36.4X5*, T36.5X1*-T36.5X5*, T36.6X1*- T36.6X5*, T36.7X1*-T36.7X5*, T36.8X1*-T36.8X5*, T36.91X*-T36.95X*, T37.0X1*-T37.0X5*, T37.1X1*-T37.1X5*, T37.2X1*-T37.2X5*, T37.3X1*- T37.3X5*, T37.4X1*-T37.4X5*, T37.5X1*-T37.5X5*, T37.8X1*-T37.8X5*, T37.91X*-T37.95X*, T38.0X1*-T38.0X5*, T38.1X1*-T38.1X5*, T38.2X1*- T38.2X5*, T38.3X1*-T38.3X5*, T38.4X1*-T38.4X5*, T38.5X1*-T38.5X5*, T38.6X1*-T38.6X5*, T38.7X1*-T38.7X5*, T38.801*-T38.805*, T38.811*- T38.815*, T38.891*-T38.895*, T38.901*-T38.905*, T38.991*-T38.995*, T39.011*- T39.015*, T39.091*-T39.095*, T39.1X1*-T39.1X5*, T39.2X1*-T39.2X5*, T39.311*-T39.315*, T39.391*-T39.395*, T39.4X1*-T39.4X5*, T39.8X1*- T39.8X5*, T39.91X*-T39.95X*, T40.0X1*-T40.0X5*, T40.1X1*-T40.1X4*, T40.2X1*-T40.2X5*, T40.3X1*-T40.3X5*, T40.4X1*-T40.4X5*, T40.5X1*- T40.5X5*, T40.601*-T40.605*, T40.691*-T40.695*, T40.7X1*-T40.7X5*, T40.8X1*-T40.8X4*, T40.901*-T40.905*, T40.991*-T40.995*, T41.0X1*- T41.0X5*, T41.1X1*-T41.1X5*, T41.201*-T41.205*, T41.291*-T41.295*, T41.3X1*-T41.3X5*, T41.41X*-T41.45X*, T41.5X1*-T41.5X5*, T42.0X1*- T42.0X5*, T42.1X1*-T42.1X5*, T42.2X1*-T42.2X5*, T42.3X1*-T42.3X5*, T42.4X1*-T42.4X5*, T42.5X1*-T42.5X5*, T42.6X1*-T42.6X5*, T42.71X*- T42.75X*, T42.8X1*-T42.8X5*, T43.011*-T43.015*, T43.021*-T43.025*, T43.1X1*-T43.1X5*, T43.201*-T43.205*, T43.211*-T43.215*, T43.221*-T43.225*, T43.291*-T43.295*, T43.3X1*-T43.3X5*, T43.4X1*-T43.4X5*, T43.501*- T43.505*, T43.591*-T43.595*, T43.601*-T43.605*, T43.611*-T43.615*, T43.621*- T43.625*, T43.631*-T43.635*, T43.691*-T43.695*, T43.8X1*-T43.8X5*, T43.91X*-T43.95X*, T44.0X1*-T44.0X5*, T44.1X1*-T44.1X5*, T44.2X1*- 10 Revised April 2014

11 T44.2X5*, T44.3X1*-T44.3X5*, T44.4X1*-T44.4X5*, T44.5X1*-T44.5X5*, T44.6X1*-T44.6X5*, T44.7X1*-T44.7X5*, T44.8X1*-T44.8X5*, T44.901*- T44.906*, T44.991*-T44.995*, T45.0X1*-T45.0X5*, T45.1X1*-T45.1X5*, T45.2X1*-T45.2X5*, T45.3X1*-T45.3X5*, T45.4X1*-T45.4X5*, T45.511*- T45.515*, T45.521*-T45.525*, T45.601*-T45.605*, T45.611*-T45.615*, T45.621*- T45.625*, T45.691*-T45.695*, T45.7X1*-T45.7X5*, T45.8X1*-T45.8X5*, T45.91X*-T45.95X*, T46.0X1*-T46.0X5*, T46.1X1*-T46.1X5*, T46.2X1*- T46.2X5*, T46.3X1*-T46.3X5*, T46.4X1*-T46.4X5*, T46.5X1*-T46.5X5*, T46.6X1*-T46.6X5*, T46.7X1*-T46.7X5*, T46.8X1*-T46.8X5*, T46.901*- T46.905*, T46.991*-T46.995*, T47.0X1*-T47.0X5*, T47.1X1*-T47.1X5*, T47.2X1*-T47.2X5*, T47.3X1*-T47.3X5*, T47.4X1*-T47.4X5*, T47.5X1*- T47.5X5*, T47.6X1*-T47.6X5*, T47.7X1*-T47.7X5*, T47.8X1*-T47.8X5*, T47.91X*-T47.95X*, T48.0X1*-T48.0X5*, T48.1X1*-T48.1X5*, T48.201*- T48.205*, T48.291*-T48.295*, T48.3X1*-T48.3X5*, T48.4X1*-T48.4X5*, T48.5X1*-T48.5X5*, T48.6X1*-T48.6X5*, T48.901*-T48.905*, T48.991*- T48.995*, T49.0X1*-T49.0X5*, T49.1X1*-T49.1X5*, T49.2X1*-T49.2X5*, T49.3X1*-T49.3X5*, T49.4X1*-T49.4X5*, T49.5X1*-T49.5X5*, T49.6X1*- T49.6X5*, T49.7X1*-T49.7X5*, T49.8X1*-T49.8X5*, T49.91X*-T49.95X*, T50.0X1*-T50.0X5*, T50.1X1*-T50.1X5*, T50.2X1*-T50.2X5*, T50.3X1*- T50.3X5*, T50.4X1*-T50.4X5*, T50.5X1*-T50.5X5*, T50.6X1*-T50.6X5*, T50.7X1*-T50.7X5*, T50.8X1*-T50.8X5*, T50.901*-T50.905*, T50.991*- T50.995*, T50.A11*-T50.A15*, T50.A21*-T50.A25*, T50.A91*-T50.A95*, T50.B11*-T50.B15*, T50.B91*-T50.B95*, T50.Z11*-T50.Z15*, T50.Z91*- T50.Z95*, T50.0X1*-T51.94X*, T52.0X1*-T52.94X*, T53.0X1*-T53.94X*, T54.0X1*-T54.94X*, T55.0X1*-T55.1X4*, T56.0X1*-T56.94X*, T57.0X1*- T57.94X*, T58.01X*-T58.94X*, T59.0X1*-T59.94X*, T60.0X1*-T60.94X*, T61.01X*-T61.94X*, T62.0X1*-T62.94X*, T63.001*-T63.094*, T63.111*- T63.194*, T63.2X1*-T63.2X4*, T63.301*-T63.394*, T63.411*-T63.484*, T63.511*-T63.594*, T63.611*-T63.694*, T63.711*-T63.794*, T63.811*-T63.894*, T63.91X*-T63.94X*, T64.01X*-T64.84X*, T65.0X1*-T65.94X*, T66.XXX*, T67.0XX*-T67.9XX*, T68.XXX*, T69.011*-T69.9XX*, T70.0XX*-T70.9XX*, T71.111*-T71.9XX*, T73.0XX*-T73.9XX*, T74.01X*-T74.92X*, T75.00X*- T75.89X*, T76.01X*-T76.92X*, T78.00X*-T78.8XX*, T79.0XX*-T79.9XX*, T80.0XX*-T80.1XX*, T80.29X*-T80.92X*, T81.30X*-T81.9XX*, T82.01X*- T82.9XX*, T83.010*-T83.6XX*, T83.81X*-T83.99X*, T84.010*-T84.099*, T84.110*-T84.199*, T84.210*-T84.298*, T84.310*-T84.398*, T84.410*-T84.498*, T84.50X*-T84.59X*, T84.60X*-T84.69X*, T84.7XX*, T84.81X*-T84.89X*, T84.9XX*, T85.01X*-T85.9XX*, T88.0XX*-T88.9XX* IV Drug Abuse: (Within twelve months prior to MRI procedure. An exclusion ICD-10 codes: F11.10-F11.120, F11.129, F11.20-F11.29, F13.10-F13.120, F F13.21, F14.10-F14.120, F14.20-F14.29, F15.10-F15.120, F15.20-F Revised April 2014

12 Neurologic Impairment: (Within twelve months prior to MRI procedure. An exclusion ICD-10 codes: G83.4, M54.10, M54.18, M79.2 Human Immunodeficiency Virus (HIV): (Within twelve months prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 codes: B20 Unspecified Immune Deficiencies: (Within twelve months prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or ICD-10 code: D84.8-D84.9 Intraspinal abscess: (An exclusion diagnosis must be in one of the diagnoses fields on the MRI lumbar spine claim.) ICD-10 codes: G06.1-G07 Technical Note: Please note that an asterisk (*) represents a wildcard for that digit. Technical Note: The draft specifications included in this document represent a crosswalk of the ICD-9 specifications to ICD-10 specifications based on both a forward and backward crosswalk of the General Equivalence Mapping (GEM) file. The contractor made additional modifications to the ICD-10 specifications as a result of public comment and review by contractor clinicians and ICD-10 subject matter experts. Additional refinement of the ICD-10 specifications may occur as data comes available for testing. Disclaimer: CPT codes, descriptions, and other data only are copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. 12 Revised April 2014

OP-14: SIMULTANEOUS USE OF BRAIN COMPUTED TOMOGRAPHY (CT) AND SINUS COMPUTED TOMOGRAPHY (CT)

OP-14: SIMULTANEOUS USE OF BRAIN COMPUTED TOMOGRAPHY (CT) AND SINUS COMPUTED TOMOGRAPHY (CT) Description of Measure This measure calculates the percentage of Brain CT studies with a simultaneous Sinus