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

Measure Information 2025 Reporting Period
Title Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Facility IQR)
CMS eCQM ID CMS1074v2
Short Name

IP-ExRad

CBE ID* 3663e
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. This measure is expressed as a percentage of 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 facility. A parallel eCQM measures CT exams aggregated at the level of the clinician or clinician group. A single CT exam may be simultaneously measured in...

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Initial Population

All CT scans in adults aged 18 years and older at the start of the measurement period that have a CT Dose and Image Quality Category and were performed during an inpatient hospitalization during the measurement period

Denominator

Equals Initial population with a CT Dose and Image Quality Category, a Calculated Global Noise value, and a Calculated CT Size-Adjusted Dose value

Denominator Exclusions

Denominator, where a CT scan with a CT Dose and Image Quality Category = full body

Numerator

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 Category

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Next Version No Version Available
Previous Version No Version Available
  1. There is a known issue on CMS1074v2. See issue EKI-36 on the ONC eCQM Known Issues Dashboard for details.
  2. Beginning with the Calendar Year 2025 performance period, hospitals and clinicians who choose to report this eCQM may use any vendor’s software that meets the necessary requirements to generate the standardized data elements required to calculate the measure, consistent with the measure’s specifications. Hospitals and clinicians are not required to use the Alara Imaging Software for CMS measure compliance. Any software vendor capable of calculating and reporting this eCQM in accordance with the measure’s specifications, including transforming radiology data into a format compatible with eCQM reporting, may report this measure on behalf of hospitals and clinicians. Hospitals and clinicians are not required to demonstrate to CMS that the software they or their vendors use can generate and transform the radiology data into the necessary format.  However, nothing would prevent a hospital or clinician seeking assurance about the ability of specific software to perform these tasks from requesting that information from a vendor.

    As with all eCQMs, CMS will monitor measure results to ensure that all reported data for the Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography in AdultseCQM are both reliable and valid. This may include analyzing data to identify outliers and common characteristics of outlier submissions.

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 Description to clarify that this is an episode of care measure.

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

    Measure Section:

    Guidance

    Source of Change:

    ONC Project Tracking System (JIRA): CQM-6245

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

    Measure Section:

    Multiple Sections

    Source of Change:

    Measure Lead

  • 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 timing logic in the Initial Population to 'ends during day' of measurement period to align with measure logic and intent.

    Measure Section:

    Initial Population

    Source of Change:

    Standards/Technical Update

  • Updated aliases 'CTScan' in the Denominator and Denominator Exclusions to align with the CQL Style Guide.

    Measure Section:

    Denominator

    Source of Change:

    Standards/Technical Update

  • Updated aliases 'CTScan' in the Denominator and Denominator Exclusions to align with the CQL Style Guide.

    Measure Section:

    Denominator Exclusions

    Source of Change:

    Standards/Technical Update

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

    Measure Section:

    Denominator Exclusions

    Source of Change:

    ONC Project Tracking System (JIRA): CQM-6245

  • 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

  • Revised population aliases in the logic to reduce unnecessary duplication and align with measure logic and intent.

    Measure Section:

    Definitions

    Source of Change:

    Standards/Technical Update

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

    Measure Section:

    Definitions

    Source of Change:

    ONC Project Tracking System (JIRA): CQM-6245

  • 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

  • Created a shared Library for common functions: 'Qualifies,' 'CT Scan Qualifies,' 'Global Noise Value,' and 'Size Adjusted Value,' allowing use in multiple measures.

    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: Feb 04, 2025