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

Compare Versions of: "Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Facility IQR)"

The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.

Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.

Compare 2026 version to

Table Options
Measure Information 2026 Reporting Period
Title Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Facility IQR)
CMS eCQM ID CMS1074v3
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 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 et al., 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

Decreased score 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

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 both the Merit-based Incentive Payment System (MIPS) and one of the hospital reporting...

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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 that ends 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

None

Denominator Exceptions

None

Next Version No Version Available
Previous Version

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

TRN

Measure Section

Source of Change

Updated 'eCQM Identifier (Measure Authoring Tool)' field to 'CMS ID' based on tooling update.

CMS ID

Standards/Technical Update

Updated the eCQM version number.

eCQM Version Number

Annual Update

Updated measurement period to reflect exact dates of reporting.

Measurement Period

Standards/Technical Update

Updated copyright.

Copyright

Annual Update

Updated disclaimer.

Disclaimer

Annual Update

Updated measure type from 'Intermediate Clinical Outcome' to 'Intermediate Outcome' based on new tooling requirements.

Measure Type

Annual Update

Updated Improvement Notation field to read 'Decreased score indicates improvement' based on tooling update to promote alignment across measures.

Improvement Notation

Standards/Technical Update

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

Multiple Sections

Annual Update

Updated the Initial Population statement to specify that inpatient hospitalizations must end during the measurement period to clarify measure intent and align the narrative and logic.

Initial Population

ONC Project Tracking System (JIRA): CQM-7387

Updated Numerator Exclusions field to read 'None' instead of 'Not Applicable' when no exclusions present to promote alignment across header fields.

Numerator Exclusions

Standards/Technical Update

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

Multiple Sections

Annual Update

Logic

TRN

Measure Section

Source of Change

Updated the CQL library name from 'CMS1074-v2-0-000-QDM-5-6.cql' to 'CMS1074CTIQR-3.3.000.cql' based on recommendation by technical experts.

Definitions

Standards/Technical Update

Updated measure logic used for the Initial Population to include CT scans that occur during encounters that end during the measurement period, resolving a known issue with the measure and harmonizing the measure with existing hospital eCQMs.

Definitions

ONC Project Tracking System (JIRA): CQM-7387

Updated the library name from 'AlaraCommonFunctions' to 'AlaraCommonFunctionsQDM'.

Definitions

Annual Update

Updated the version number of the Global Shared Library to v9.0.000 and the library name from 'MATGlobalCommonFunctionsQDM' to 'CQMCommonQDM'.

Definitions

Annual Update

Updated the version number of the Global Shared Library to v9.0.000 and the library name from 'MATGlobalCommonFunctionsQDM' to 'CQMCommonQDM'.

Functions

Annual Update

Updated the library name from 'AlaraCommonFunctions' to 'AlaraCommonFunctionsQDM'.

Functions

Annual 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.

TRN

Measure Section

Source of Change

Replaced value set used for Sex Supplemental Data Element (SDE) ONC Administrative Sex (2.16.840.1.113762.1.4.1) with value set Federal Administrative Sex (2.16.840.1.113762.1.4.1021.121) based on updated standards.

Terminology

Standards/Technical Update

Last Updated: May 06, 2025