Resources

We have adopted recommendations from the National Committee for Quality Assurance (NCQA) and multiple professional societies regarding reimbursement for imaging studies. 

These recommendations are reflected in our Low-Back Pain Imaging Study Quality measure that evaluates the percentage of patients ages 18 – 75 who did not have an imaging study (e.g., x-ray, MRI, CT scan) done within 28 days of the diagnosis. 

Your patient is included in this measure if the criteria below are met: 

• The patient had an imaging study for a principal diagnosis of uncomplicated low-back pain and had at least one ED, observation or outpatient visit that didn’t result in an inpatient stay. 

OR

• The patient received at least one osteopathic or chiropractic manipulation, physical therapy, or a telephone or online assessment visit with a principal diagnosis of uncomplicated low-back pain. 

Your patients who meet the above criteria can be excluded from this measure if they meet the additional criteria in our Self-Audit Checklist and if your records meet our Medical Record Documentation Guidelines. Refer to the Low-Back Pain Imaging Study Quality measure for more information and specific codes. 

View these resources to determine if your patient meets these criteria. If so, the claim for low-back pain imaging can be filed with the KX modifier, which means it will be paid and the patient will be excluded from the Low-Back Pain Imaging Studies measure. 

Claims for low-back pain imaging provided to Federal Employee Program (FEP) members ages 18 – 75 (excluding facility and emergency room claims) must meet these guidelines or the claims are subject to rejection. 

For more information regarding imaging for uncomplicated low-back pain, view “Use of Imaging Studies for Low-Back Pain” on the NCQA website.