Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture
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| Measure Information | 2022 Performance Period | 2023 Performance Period | 2024 Performance Period |
|---|---|---|---|
| Title | Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture | Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture | Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture |
| CMS eCQM ID | CMS249v4 | CMS249v5 | CMS249v6 |
| CBE ID* | 3475e | 3475e | 3475e |
| MIPS Quality ID | 472 | 472 | 472 |
| Measure Steward | Centers for Medicare & Medicaid Services (CMS) | Centers for Medicare & Medicaid Services (CMS) | Centers for Medicare & Medicaid Services (CMS) |
| Description |
Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period |
Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period |
Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process | Process | Process |
| Stratification | *See CMS249v4.html | *See CMS249v5.html |
None |
| Risk Adjustment | *See CMS249v4.html | *See CMS249v5.html |
None |
| Rationale | *See CMS249v4.html | *See CMS249v5.html |
This measure is expected to increase recording of patient risk for fracture data and decrease the amount of inappropriate DXA scans. Current osteoporosis guidelines recommend using bone measurement testing to assess osteoporosis risk in women 65 years and older. In postmenopausal women younger than age 65, guidelines recommend using a formal clinical risk assessment tool to establish a patient's risk for osteoporosis, in order to determine whether to screen a patient for osteoporosis using bone measurement testing. Clinical information, such as age, body mass index (BMI), parental hip fracture history, and alcohol use, can be used to determine a woman's fracture risk (U.S. Preventive Services Task Force [USPSTF], 2018). Additionally, there are potentially avoidable harms associated with screening for osteoporosis in general, including exposure to radiation, false positive exams, and resulting side effects from unnecessary osteoporosis medications, which add costs to an already burdened health care system (Lim, Hoeksema, & Sherin, 2009). |
| Clinical Recommendation Statement | *See CMS249v4.html | *See CMS249v5.html |
USPSTF: "The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older." This is a B recommendation. "The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in men." This is an I statement. "The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool." This is a B recommendation. "For postmenopausal women younger than 65 years who have at least 1 risk factor, a reasonable approach to determine who should be screened with bone measurement testing is to use a clinical risk assessment tool." "Several tools are available to assess osteoporosis risk: the Simple Calculated Osteoporosis Risk Estimate (SCORE; Merck), Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Index of Risk (OSIRIS), and the Osteoporosis Self-Assessment Tool (OST). These tools seem to perform similarly and are moderately accurate at predicting osteoporosis. The Fracture Risk Assessment (FRAX) tool (University of Sheffield), which assesses a person's 10-year risk of fracture, is also a commonly used tool." "Because the benefits of treatment are greater in persons at higher risk of fracture, one approach is to perform bone measurement testing in postmenopausal women younger than 65 years who have a 10-year FRAX risk of major osteoporotic fracture (MOF) (without DXA) greater than that of a 65-year-old white woman without major risk factors. For example, in the United States, a 65-year-old white woman of mean height and weight without major risk factors has a 10-year FRAX risk of MOF of 8.4%." |
| Improvement Notation |
Lower score indicates better quality |
Lower score indicates better quality |
Lower score indicates better quality |
| Definition | *See CMS249v4.html | *See CMS249v5.html |
The measure allows for clinicians to use 4 tools to assess osteoporosis or osteoporotic fracture risk. 1. The Fracture Risk Assessment Tool (FRAX[R]) is used to calculate 10-year absolute fracture risk. The FRAX evaluates a patient's 10-year probability of hip fracture and major osteoporotic fracture (clinical spine, forearm, hip, or shoulder fracture). It is applicable to people aged 40-90 years. 2. The Osteoporosis Risk Assessment Instrument (ORAI) is used to calculate osteoporosis risk. It is applicable to women >=45 years. 3. The Osteoporosis Index of Risk (OSIRIS) is used to calculate osteoporosis risk. It is applicable to patients of any age. 4. The Osteoporosis Self-Assessment Tool (OST) is used to calculate osteoporosis risk. It is applicable to patients of any age. |
| Guidance |
There are two ways that a patient can be excluded from the measure: 1. The patient has a specific number of "combination" risk factors (the number of risk factors varies by age). 2. The patient has one or more of the "independent" risk factors, including a 10-year probability of major osteoporotic fracture of 8.4 percent or higher as determined by the FRAX. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
Patients are excluded from the measure if they have one or more risk factors for osteoporosis, including a result indicating that the patient should be considered for bone density testing on one of the following risk assessment instruments: • 10-year probability of major osteoporotic fracture of 8.4 percent or higher as determined by the FRAX • ORAI score of >=9 • OSIRIS score of <1 • OST score of <2 This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
Patients are excluded from the measure if they have one or more risk factors for osteoporosis, including a result indicating that the patient should be considered for bone density testing on one of the following risk assessment instruments: - 10-year probability of major osteoporotic fracture of 8.4 percent or higher as determined by the FRAX - ORAI score of >=9 - OSIRIS score of <1 - OST score of <2 This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| Initial Population |
Female patients ages 50 to 64 years with an encounter during the measurement period |
Female patients ages 50 to 63 years at the start of the measurement period with an encounter during the measurement period |
Female patients ages 50 to 63 years at the start of the measurement period with an encounter during the measurement period |
| Denominator |
Equals Initial Population |
Equals Initial Population |
Equals Initial Population |
| Denominator Exclusions |
Exclude patients with a combination of risk factors (as determined by age) or one of the independent risk factors Ages: 50-54 (>=4 combination risk factors) or 1 independent risk factor Ages: 55-59 (>=3 combination risk factors) or 1 independent risk factor Ages: 60-64 (>=2 combination risk factors) or 1 independent risk factor COMBINATION RISK FACTORS [The following risk factors are all combination risk factors; they are grouped by when they occur in relation to the measurement period]: The following risk factors may occur any time in the patient's history but must be active during the measurement period: White (race) BMI <= 20 kg/m2 (must be the first BMI of the measurement period) Smoker (current during the measurement period) Alcohol consumption (> two units per day (one unit is 12 oz. of beer, 4 oz. of wine, or 1 oz. of liquor)) The following risk factor may occur any time in the patient's history and must not start during the measurement period: Osteopenia The following risk factors may occur at any time in the patient's history or during the measurement period: Rheumatoid arthritis Hyperthyroidism Malabsorption Syndromes: celiac disease, inflammatory bowel disease, ulcerative colitis, Crohn's disease, cystic fibrosis, malabsorption Chronic liver disease Chronic malnutrition Osteoporotic fracture The following risk factors may occur any time in the patient's history prior to the start of the measurement period but do not need to be active at the start of the measurement period: Documentation of history of hip fracture in parent Glucocorticoids [cumulative medication duration >= 90 days] INDEPENDENT RISK FACTORS (The following risk factors are all independent risk factors; they are grouped by when they occur in relation to the measurement period): The following risk factors may occur at any time in the patient's history and must not start during the measurement period: Osteoporosis The following risk factors may occur at any time in the patient's history prior to the start of the measurement period, but do not need to be active during the measurement period: Gastric bypass FRAX[R] ten-year probability of all major osteoporosis related fracture >= 8.4 percent Aromatase inhibitors The following risk factors may occur at any time in the patient's history or during the measurement period: Type I Diabetes End stage renal disease Osteogenesis imperfecta Ankylosing spondylitis Psoriatic arthritis Ehlers-Danlos syndrome Cushing's syndrome Hyperparathyroidism Marfan syndrome Lupus |
Exclude patients with one of the following risk factors. Risk factors are grouped by when they occur in relation to the measurement period. The following risk factors must be active during the measurement period: BMI <= 20 kg/m2 (must be the first BMI of the measurement period) Alcohol consumption (> two units per day (one unit is 12 oz. of beer, 4 oz. of wine, or 1 oz. of liquor)) The following risk factors may occur at any time in the patient's history prior to the start of the measurement period: Osteoporosis Osteopenia The following risk factors may occur at any time in the patient's history prior to the start of the measurement period, but do not need to be active during the measurement period: Gastric bypass Aromatase inhibitors Documentation of history of hip fracture in parent The following risk factors may occur at any time in the patient's history or during the measurement period: Glucocorticoids [cumulative medication duration >= 90 days] Osteoporotic fracture Malabsorption Syndromes: celiac disease, inflammatory bowel disease, ulcerative colitis, Crohn's disease, cystic fibrosis, malabsorption Chronic malnutrition Chronic liver disease Rheumatoid arthritis Hyperthyroidism Type I Diabetes End stage renal disease Osteogenesis imperfecta Ankylosing spondylitis Psoriatic arthritis Ehlers-Danlos syndrome Cushing's syndrome Hyperparathyroidism Marfan syndrome Lupus Chemotherapy Multiple myeloma Premature menopause Double or bilateral oophorectomy Eating disorder Amenorrhea Organ transplant |
Exclude patients with one of the following risk factors. Risk factors are grouped by when they occur in relation to the measurement period. The following risk factors must be active during the measurement period: BMI <= 20 kg/m2 (must be the first BMI of the measurement period) Alcohol consumption (> two units per day (one unit is 12 oz. of beer, 4 oz. of wine, or 1 oz. of liquor)) The following risk factors may occur at any time in the patient's history prior to the start of the measurement period: Osteoporosis Osteopenia Gastric bypass Aromatase inhibitors Documentation of history of hip fracture in parent The following risk factors may occur at any time in the patient's history or during the measurement period: Glucocorticoids [cumulative medication duration >= 90 days] Osteoporotic fracture Malabsorption Syndromes: celiac disease, inflammatory bowel disease, ulcerative colitis, Crohn's disease, cystic fibrosis, malabsorption Chronic malnutrition Chronic liver disease Rheumatoid arthritis Hyperthyroidism Type I Diabetes End stage renal disease Osteogenesis imperfecta Ankylosing spondylitis Psoriatic arthritis Ehlers-Danlos syndrome Cushing's syndrome Hyperparathyroidism Marfan syndrome Lupus Chemotherapy Multiple myeloma Premature menopause Double or bilateral oophorectomy Eating disorder Amenorrhea Organ transplant |
| Numerator |
Female patients who received an order for at least one DXA scan in the measurement period |
Female patients who received an order for at least one DXA scan in the measurement period |
Female patients who received an order for at least one DXA scan in the measurement period |
| Numerator Exclusions |
Not Applicable |
Exclude patients with a result on one of the following tools, which indicates the patient should be considered for bone density testing, anytime in the patient’s history prior to the time of the first DXA scan during the measurement period: FRAX[R] ten-year probability of all major osteoporosis related fracture >= 8.4 percent ORAI score of >=9 OSIRIS score of <1 OST score of <2 |
Exclude patients with a result on one of the following tools, which indicates the patient should be considered for bone density testing, anytime in the patient’s history prior to the time of the first DXA scan during the measurement period: FRAX[R] ten-year probability of all major osteoporosis related fracture >= 8.4 percent ORAI score of >=9 OSIRIS score of <1 OST score of <2 |
| Denominator Exceptions |
None |
None |
None |
| Telehealth Eligible | Yes | Yes | Yes |
| Next Version | No Version Available | ||
| Previous Version | No Version Available |
Additional Resources for CMS249v6
Header
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
Simplified language to group exclusions with similar timings to improve clarity and understanding, without changing intent.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
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Measure Section: Multiple Sections
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Logic
Simplified logic to group exclusions with similar timings to improve clarity and understanding, without changing intent.
Measure Section: Denominator Exclusions
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Expanded the specific codes to assess alcohol assumption, per standards recommendation.
Measure Section: Definitions
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Simplified logic to group exclusions with similar timings to improve clarity and understanding, without changing intent.
Measure Section: Definitions
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Value Set
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Replaced direct reference code LOINC code (11287-0) with value set Average Number of Drinks per Drinking Day (2.16.840.1.113883.3.464.1003.106.12.1018) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
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Value set Chronic Liver Disease (2.16.840.1.113883.3.464.1003.199.12.1035): Added 4 SNOMED CT codes (838377003, 871619002, 10690671000119109, 870517000) based on review by technical experts, SMEs, and/or public feedback. Deleted 2 SNOMED CT codes (111370006, 197304003) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
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Value set Chronic Malnutrition (2.16.840.1.113883.3.464.1003.199.12.1036): Added 1 SNOMED CT code (870568002) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
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Value set Eating Disorders (2.16.840.1.113883.3.464.1003.1039): Added 3 SNOMED CT codes (231521002, 1186723008, 1197718003) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
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Value set Lupus (2.16.840.1.113883.3.464.1003.117.12.1010): Added 1 SNOMED CT code (773333003) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 SNOMED CT code (95408003) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Malabsorption Syndromes (2.16.840.1.113883.3.464.1003.199.12.1050): Deleted 4 SNOMED CT codes (65328007, 190753003, 190909002, 197479008) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
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Value set Online Assessments (2.16.840.1.113883.3.464.1003.101.12.1089): Added 4 CPT codes (98980, 98981, 99444, 99457) based on review by technical experts, SMEs, and/or public feedback. Added 3 HCPCS codes (G2250, G2251, G2252) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Osteoporosis (2.16.840.1.113883.3.464.1003.113.12.1038): Added 3 SNOMED CT codes (203450003, 203451004, 203452006) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Payer (2.16.840.1.114222.4.11.3591): Added 5 SOP codes (1111, 1112, 142, 344, 141) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
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Value set Type 1 Diabetes (2.16.840.1.113883.3.464.1003.103.12.1020): Deleted 3 SNOMED CT codes (190369008, 237618001, 314771006) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead