HEDIS® Tip Sheet

Use of Imaging Studies for Low Back Pain (LBP)

Measure Description

Percentage of members 18–75 years of age with a principal diagnosis of low back pain who did not have an imaging study (X-ray, MRI, CT scan) within 28 days of the diagnosis.

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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 members with a primary diagnosis of uncomplicated low back pain in an outpatient setting who did not have an imaging study (e.g. standard X-ray, MRI, or CT scan) within 28 days following the diagnosis. 

Notes

  • This measure applies to members ages 18-75 years as of December 31st of the measurement year.
  • Laboratory claims (claims with POS code 81) are not included in this measure.
  • This measure is reported as an inverted rate. A higher score indicates appropriate treatment of low back pain. 
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Exclusions

  • Members with a diagnosis of uncomplicated low back pain within the 6 months prior.
  • Cancer, HIV, organ transplant, osteoporosis or osteoporosis medications, lumbar 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.
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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.

Coding and Benefits Disclaimer

Providers and organizations must submit accurate and complete data in accordance with all billing, coding, and medical policy requirements. HEDIS guidance does not override official coding standards or guarantee reimbursement, as coverage is subject to applicable medical/coding policy and member-specific benefits.

Questions

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

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Updated 8/28/2026