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... 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 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...Show more > |
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 |
- There is a known issue on CMS1074v2. See issue EKI-36 on the ONC eCQM Known Issues Dashboard for details.
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.
Additional Resources for CMS1074v2
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 Description to clarify that this is an episode of care measure.
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Description
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Standards/Technical Update
Updated copyright.
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Copyright
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Annual Update
Updated disclaimer.
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Disclaimer
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Annual Update
Clarified how CT category is communicated in the Guidance to align with QRDA I requirements.
Measure Section:
Guidance
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ONC Project Tracking System (JIRA): CQM-6245
Updated grammar, wording, and/or formatting to improve readability and consistency.
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Multiple Sections
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Measure Lead
Updated references and measure header to reflect current evidence and new or updated literature.
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Multiple Sections
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Logic
Updated timing logic in the Initial Population to 'ends during day' of measurement period to align with measure logic and intent.
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Initial Population
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Standards/Technical Update
Updated aliases 'CTScan' in the Denominator and Denominator Exclusions to align with the CQL Style Guide.
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Denominator
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Standards/Technical Update
Updated aliases 'CTScan' in the Denominator and Denominator Exclusions to align with the CQL Style Guide.
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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
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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.
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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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Measure Lead
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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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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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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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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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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Measure Lead
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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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.
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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
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Measure Lead