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Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Level)

Measure Information 2025 Performance Period
Title Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Level)
CMS eCQM ID CMS1056v2
CBE ID* 3633e
MIPS Quality ID 494
Measure Steward Alara Imaging, Inc.
Description

This measure provides a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality. It is expressed as a percentage of patients with CT exams that are out-of-range based on...

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Measure Scoring Proportion measure
Measure Type Intermediate Clinical Outcome
Stratification

None

Risk Adjustment

None

Rationale

Diagnostic imaging using CT occurs in more than a third of acute care hospitalizations in the U.S. (Vance, 2013) and greater than 90 million scans are performed annually in the U.S. (IMV, 2019). There is marked observed variation in the radiation doses used to perform these exams...

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Clinical Recommendation Statement

The measure aligns with numerous evidence- and consensus-based clinical guidelines asking radiologists to track, optimize, and lower CT radiation doses, guidelines that have been written by the American College of Radiology (Kanal, 2017), cardiovascular imaging societies (Hirshfeld,...

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Improvement Notation

Lower score indicates higher quality, and a decreased score over time indicates improvement

Definition

CT Dose and Image Quality Category: reflects the type of exam performed based on body region and clinical indication. Each CT Dose and Image Quality Category has a specific set of dose and image quality (global noise) thresholds.

Calculated CT Size-Adjusted Dose: reflects the total...

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Guidance

This is an inverse measure; as such the higher the value the worse the performance.

The level of aggregation for this eCQM is the clinician. Parallel eCQMs report CT exams performed in inpatient and outpatient hospital settings and is aggregated on the facility level. A single CT exam may...

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Initial Population

Patients aged 18 years and older at the start of the measurement period that have an eligible CT scan with Dose and Image Quality Category performed during the measurement period

Denominator

Equals Initial Population where an eligible CT scan has a Calculated Global Noise value and a Calculated CT Size-Adjusted Dose value

Denominator Exclusions

Patients with one or more eligible CT scans that has a CT Dose and Image Quality Category = full body

Numerator

Patients with one or more eligible CT scans with calculated CT Size-Adjusted Dose greater than or equal to a threshold specific to the CT Dose and Image Quality Category, or Calculated CT Global Noise value greater than or equal to a threshold specific to the CT Dose and Image Quality...

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Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Telehealth Eligible No
Next Version No Version Available
Previous Version No Version Available

Header

  • Updated the eCQM version number.

    Measure Section:

    eCQM Version Number

    Source of Change:

    Annual Update

  • Changed all references from NQF to CBE to identify the consensus-based entity role.

    Measure Section:

    CBE Number

    Source of Change:

    Annual Update

  • Updated CBE Number to remove an additional endorsement number.

    Measure Section:

    CBE Number

    Source of Change:

    Standards/Technical Update

  • Added language to the Description to clarify the measure is not telehealth eligible.

    Measure Section:

    Description

    Source of Change:

    Standards/Technical Update

  • Updated language in the Description to clarify measure is patient-based.

    Measure Section:

    Description

    Source of Change:

    Standards/Technical Update

  • Updated copyright.

    Measure Section:

    Copyright

    Source of Change:

    Annual Update

  • Updated disclaimer.

    Measure Section:

    Disclaimer

    Source of Change:

    Annual Update

  • Clarified the level of aggregation in the Guidance to reflect that the 'level of aggregation for this eCQM is the clinician,' aligning with the measure title and CBE endorsement.

    Measure Section:

    Guidance

    Source of Change:

    Measure Lead

  • Clarified how CT category variable is communicated in the Guidance to align with QRDA I requirements.

    Measure Section:

    Guidance

    Source of Change:

    Measure Lead

  • Updated language in the Initial Population to clarify measure is patient-based.

    Measure Section:

    Initial Population

    Source of Change:

    Standards/Technical Update

  • Added the word 'equals' to the Denominator description in the header for consistency across quality measures.

    Measure Section:

    Denominator

    Source of Change:

    Measure Lead

  • Updated language in the Numerator to clarify measure is patient-based.

    Measure Section:

    Numerator

    Source of Change:

    Standards/Technical Update

  • Updated grammar, wording, and/or formatting to improve readability and consistency.

    Measure Section:

    Multiple Sections

    Source of Change:

    Annual Update

  • Updated references and measure header to reflect current evidence and new or updated literature.

    Measure Section:

    Multiple Sections

    Source of Change:

    Measure Lead

Logic

  • Updated measure to refer to CT LOINC code to eliminate QRDA report error. Denominator Exclusions now refer to LOINC code rather than the code descriptor.

    Measure Section:

    Denominator Exclusions

    Source of Change:

    Measure Lead

  • Updated Definition to more accurately reflect the contents and intent of the value set and to align with C-CDA and US Core updates and releases.

    Measure Section:

    Definitions

    Source of Change:

    Standards/Technical Update

  • Renamed value set to 'Payer Type' to more accurately reflect the contents and intent of the value set.

    Measure Section:

    Definitions

    Source of Change:

    Standards/Technical Update

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'

    Measure Section:

    Definitions

    Source of Change:

    Annual Update

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'

    Measure Section:

    Functions

    Source of Change:

    Annual Update

  • Changed 'CT Scan Qualifies' function to align with CQL Style Guide.

    Measure Section:

    Functions

    Source of Change:

    Standards/Technical Update

  • Created a library containing common Numerator definitions and functions to be used across measures based on recommendation from subject matter expert.

    Measure Section:

    Multiple Sections

    Source of Change:

    Standards/Technical Update

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set (2.16.840.1.114222.4.11.3591): Renamed to Payer Type based on recommended value set naming conventions.

    Measure Section:

    Terminology

    Source of Change:

    Annual Update

  • Added direct reference code LOINC code (LA31754-7) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31752-1) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31753-9) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31761-2) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31755-4) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31756-2) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31758-8) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31759-6) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31765-3) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31771-1) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31764-6) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31762-0) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31763-8) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31766-1) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31768-7) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31770-3) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31769-5) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31851-1) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Added direct reference code LOINC code (LA31767-9) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

Last Updated: Jan 30, 2025