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... Show more > |
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... Show more > |
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,... Show more > |
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...Show more > |
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...Show more > |
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... Show more > |
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
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Annual Update
Updated CBE Number to remove an additional endorsement number.
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CBE Number
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Standards/Technical Update
Added language to the Description to clarify the measure is not telehealth eligible.
Measure Section:
Description
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Standards/Technical Update
Updated language in the Description to clarify measure is patient-based.
Measure Section:
Description
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Standards/Technical Update
Updated copyright.
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Copyright
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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
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Measure Lead
Clarified how CT category variable is communicated in the Guidance to align with QRDA I requirements.
Measure Section:
Guidance
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Measure Lead
Updated language in the Initial Population to clarify measure is patient-based.
Measure Section:
Initial Population
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Standards/Technical Update
Added the word 'equals' to the Denominator description in the header for consistency across quality measures.
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Denominator
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Measure Lead
Updated language in the Numerator to clarify measure is patient-based.
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Numerator
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Standards/Technical Update
Updated grammar, wording, and/or formatting to improve readability and consistency.
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Multiple Sections
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Annual Update
Updated references and measure header to reflect current evidence and new or updated literature.
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Multiple Sections
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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
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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
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Standards/Technical Update
Renamed value set to 'Payer Type' to more accurately reflect the contents and intent of the value set.
Measure Section:
Definitions
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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
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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
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Annual Update
Added direct reference code LOINC code (LA31754-7) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Measure Lead
Added direct reference code LOINC code (LA31752-1) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Measure Lead
Added direct reference code LOINC code (LA31753-9) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Added direct reference code LOINC code (LA31761-2) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Measure Lead
Added direct reference code LOINC code (LA31755-4) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Measure Lead
Added direct reference code LOINC code (LA31756-2) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Measure Lead
Added direct reference code LOINC code (LA31758-8) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Measure Lead
Added direct reference code LOINC code (LA31759-6) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Measure Lead
Added direct reference code LOINC code (LA31765-3) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Measure Lead
Added direct reference code LOINC code (LA31771-1) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Measure Lead
Added direct reference code LOINC code (LA31764-6) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Added direct reference code LOINC code (LA31762-0) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Measure Lead
Added direct reference code LOINC code (LA31763-8) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Measure Lead
Added direct reference code LOINC code (LA31766-1) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Measure Lead
Added direct reference code LOINC code (LA31768-7) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Measure Lead
Added direct reference code LOINC code (LA31770-3) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Measure Lead
Added direct reference code LOINC code (LA31769-5) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Measure Lead
Added direct reference code LOINC code (LA31851-1) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
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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