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HEDIS® Tip Sheet

Use of Imaging Studies for Low Back Pain (LBP)

Line of business: Commercial and Medicaid Expansion

Measure Description

Members 18–75 years of age with a principal diagnosis of low back pain who did not have an imaging study within 28 days of diagnosis.

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Notes

  • This measure applies to members ages 18-75 years as of December 31st of the measurement year.
  • This measure is reported as an inverted rate. A higher score indicates appropriate treatment of low back pain. 

Eligible Population (denominator):

  • Primary diagnosis of low back pain from January 1 to December 3rd of the measurement year. 

Measure Compliance (numerator):

  • The number of patients with a primary diagnosis of low back pain who did not have an imaging study (e.g. standard X-ray, MRI, or CT scan) within 28 days following the diagnosis.
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Best Practices

  • Encourage patients to remain active; provide education on injury prevention, safe back exercises, and appropriate use of over-the-counter pain relievers.
  • Avoid ordering imaging studies for patients with low back pain within the first 4 weeks of diagnosis unless there are clinical indications suggesting serious underlying conditions.
  • Encourage patients to establish care with a primary care provider (PCP) and educate them on the importance of routine preventive care visits.
  • When appropriate, consider referral to physical therapy or chiropractic care.
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Exclusions

  • Patients with a diagnosis of uncomplicated low back pain within the 6 months prior.
  • Cancer, HIV, major organ transplant, osteoporosis or osteoporosis medications, lumber surgery or Spondylopathy at any time in the member’s history.
  • Recent trauma or fragility fracture 3 months prior.
  • Neurologic impairment, spinal infection or IV drug abuse 1 year prior.
  • Prolonged use of corticosteroids (90 consecutive days) 1 year prior.
  • Members in hospice or palliative care during the measurement year.
  • Member who died during the measurement year.
  • Members ages 66+ as of December 31 of the measurement year with frailty and advanced illness. Must meet both criteria:
    • Frailty: at least two frailty indicators from different dates during the measurement year.
    • Advanced Illness: either two advanced illness diagnoses on different dates (current or prior year) -or- dispensed dementia medication.

Coding Disclaimer

The analysis of any medical coding question related to a measure is dependent on the measure’s technical specifications including the factual situations present related to the member, the practice, the professionals, and the medical services provided.

Questions  

Should you have specific coding or other questions related to the measure, please send your questions to BlueAlliance@bcbsnd.com.

NCQA Copyright Notice and Disclaimer
The HEDIS® measures and specifications were developed by and are owned by NCQA. The HEDIS measures and specifications are not clinical guidelines and do not establish a standard of medical care. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures and specifications. NCQA holds a copyright in these materials and can rescind or alter these materials at any time. These materials may not be modified by anyone other than NCQA. Use of the Rules for Allowable Adjustments of HEDIS to make permitted adjustments of the materials does not constitute a modification. Any commercial use and/or internal or external reproduction, distribution and publication must be approved by NCQA and are subject to a license at the discretion of NCQA. Any use of the materials to identify records or calculate measure results, for example, requires a custom license and may necessitate certification pursuant to NCQA’s Measure Certification Program. Reprinted with permission by NCQA. © [2025] NCQA, all rights reserved.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Updated 7/16/2025