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Guidelines for Imaging in Low Back Pain

Posted May 28, 2019

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Healthcare Effectiveness Data and Information Set® (HEDIS®) was developed and is maintained by the National Committee for Quality Assurance (NCQA) to standardize and measure quality for all patients. The Office of Personnel Management (OPM) reviews HEDIS performance of certain measures for Federal Employee Program® (FEP®) members. One of these measures looks at the appropriate use of all diagnostic imaging studies, including x-rays, for uncomplicated new onset lower back pain. Generally, patients with new onset low back pain diagnosis should not receive any imaging within the first 28 days of diagnosis, but rather receive conservative medical treatment with prescription strength analgesics and physical therapy. 

NCQA realizes that each patient’s presentation is unique, and imaging may be required, and has therefore added a vast number of medical conditions where imaging could be considered medically necessary on initial patient presentation. Providing the additional diagnosis in your medical evaluation when such situations present exclude such patients from your HEDIS metric. 

For information purposes only, the chart below outlines some such additional diagnoses that may present during a low back pain patient visit. 

DESCRIPTION 

ICD-10 CODE 

Cancer (active) 

All ICD-10 “C” codes 

Cancer (personal history) 

All ICD-10 “Z” codes 

HIV 

B20; Z21 

IV drug abuse 

All ICD-10 “F” codes 

Kidney transplant 

0TY00Z0-0TY00Z2; 0TY10Z0-0TY10Z2 

Major organ transplant, other than kidney 

Heart, small intestine, large intestine, liver, pancreas islets, ovaries, face, head, thymus, spleen, lungs, esophagus, stomach 

Neurologic impairment 

G83.4 

Spinal infection, osteomyelitis, and discitis 

A17.81, G06.1, M46.25-M46.28, M46.35-M46.38, M46.46-M46.48 

Trauma/fractures 

All ICD-10 “S” codes 

Note: The above list is not all inclusive. 

If you have any questions regarding the HEDIS measure for Use of Imaging in Low Back Pain, visit ncqa.org.  

HEDIS is a registered trademark of NCQA. 

The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. Physicians and other health care providers are encouraged to use their own best medical judgment based upon all available information and the condition of the patient in determining the best course of treatment.