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 ID NQF # Measure Type High Priority Measure? NQS Domain Data Submission Method(s)
145 0000 Process Yes Patient Safety
Claims

Measure Description

Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available)

Instructions

This measure is to be submitted each time fluoroscopy is performed in a hospital or outpatient setting during the performance period. There is no diagnosis associated with this measure. It is anticipated that eligible clinicians providing the services for procedures using fluoroscopy will submit this measure.

NOTE: No notes for this Quality ID

Measure Submission

The listed denominator criteria is used to identify the intended patient opulation. The numerator quality-data codes included in this specification are used to submit the quality actions allowed by the measure. All measure-specific coding should be submitted on the claim(s) representing the eligible encounter.

Numerator

Final reports for procedures using fluoroscopy that include radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available)

Definition:
Radiation exposure indices –
For the purposes of this measure, radiation exposure indices should, if possible, include at least one of the following:

  1. Skin dose mapping
  2. Peak skin dose (PSD)
  3. Reference air kerma (Ka,r)
  4. Kerma-area product (PKA) or Dose area product (DAP)

When reporting indices the report must clearly state what radiation quantity is being submitted, that is only reporting dose in mGy is insufficient. PSD in mGy is very different from Ka,r in mGy. As an example, PSD = 10. mGy or Ka,r = 10 mGy.


If the fluoroscopic equipment does not automatically provide any of the above radiation exposure indices, exposure time and the number of fluorographic images taken during the procedure may be used.

Numerator Instructions:

Data not available

Numerator Quality-Data Coding Options

Performance Met: G9500:

Radiation Exposure indices, OR Exposure Time and Number of Fluorographic Images (if radiation
exposure indices are not available) Documented in Final Procedure Report

Radiation exposure indices, OR exposure time and number of fluorographic images in final report for procedures using fluoroscopy, documented

Performance Not Met: G9501:

Radiation Exposure indices, OR Exposure Time and Number of Fluorographic Images (if radiation
exposure indices are not available) not Documented in Final Procedure Report, Reason not Given

Radiation exposure indices, OR exposure time and number of fluorographic images not documented in final report for procedure using fluoroscopy, reason not given

Numerator Note:

In interventional radiology procedures with runs, dose indices are displayed on the console and in the radiation dose structured report (RDSR). For instruments without dose indicator measurement capability, report the overall fluoroscopic time and the number of runs done where additional exposure (fluoroscopic or x-ray) occurs.
“Last image hold” is part of the fluoroscopic exam and would be included in the total fluoroscopic time. No additional radiation is involved, so the image would not be counted.
Count images where the patient received or potentially received any exposure, fluorographic or radiographic (x-ray).

Denominator

All final reports for procedures using fluoroscopy

Eligible cases are determined and must be reported, if either of the following conditions

Option 1 – Denominator Criteria (Eligible Cases):

Patient encounter during the performance period (CPT or HCPCS): 0075T, 0202T, 0234T, 0235T, 0236T, 0237T, 0238T, 0254T,0338T, 0339T, 22526*, 25606, 25651, 26608, 26650, 26676, 26706, 26727, 27235, 27244, 27245, 27509, 27756, 27759, 28406, 28436, 28456, 28476, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 36221, 36222, 36223, 36224, 36225, 36226, 36251, 36252, 36253, 36254, 36598, 36901, 36902, 36903, 36904, 36905, 36906, 37182, 37183, 37184, 37187, 37188, 37211, 37212, 37213, 37214, 37215, 37216*, 37217, 37218, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37236, 37238, 37241, 37242, 37243, 37244, 37246, 37247, 37248, 37249, 43260, 43261, 43262, 43263, 43264, 43265, 43274, 43275, 43276, 43277, 43278, 43752, 47537, 49440, 49441, 49442, 49446, 49450, 49451, 49452, 49460, 49465, 50382, 50384, 50385, 50386, 50387, 50389, 50590, 61623, 61630, 61635, 61640*, 61645, 61650, 62263, 62264, 62280, 62281, 62282, 62302, 62303, 62304, 62305, 64610, 70010, 70015, 70170, 70332, 70370, 70371, 70390, 72240, 72255, 72265, 72270, 72275, 72285, 72295, 73040, 73085, 73115, 73525, 73580, 73615, 74190, 74210, 74220, 74230, 74235, 74240, 74241, 74245, 74246, 74247, 74249, 74251, 74260, 74270, 74280, 74283, 74290, 74300, 74328, 74329, 74330, 74340, 74355, 74360, 74363, 74425, 74430, 74440, 74445, 74450, 74455, 74470, 74485, 74740, 74742, 75600, 75605, 75625, 75630, , 75705, 75710, 75716, 75726, 75731, 75733, 75736, 75741, 75743, 75746, 75756, 75801, 75803, 75805, 75807, , 75810, 75820, 75822, 75825, 75827, 75831, 75833, 75840, 75842, 75860, 75870, 75872, 75880, 75885, 75887, 75889, 75891, 75893, 75894, 75898, 75901, 75902, 75956, 75957, 75958, 75959, 75970, 76000, 76001, 76080, 76120, 76496, 77001, 77002, 77003, 92611, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93503, 93505, 93530, 93531, 93532, 93533, 93580, 93581, 93583, G0106, G0120, G0122*, G0278

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