Low back pain (LBP) is incredibly common, affecting 75% of adults at some point in their lives. Each year, 2.5 million Americans seek outpatient care for LBP. While most LBP resolves within two weeks, unnecessary imaging (X-rays, MRIs, CT scans) is often ordered. Avoiding imaging for patients when there is no indication of underlying “red flag” conditions can prevent unnecessary harm and reduce health care costs.

Healthcare Effectiveness Data and Information Set (HEDIS^®) Measure – Use of Imaging for Low Back Pain (LBP)

Compliance occurs when adults — ages 18-75 with a Principal/Primary ICD-10 diagnosis of Uncomplicated LBP — do NOT receive imaging studies within 28 days of their initial diagnosis.

Are There Conditions that Remove a Member from the HEDIS Uncomplicated LBP Measure?

Yes, the following conditions are not considered uncomplicated LBP-related. If submitted as the Principal/Primary diagnosis, imaging would be acceptable for these conditions:

• Discitis, unspecified, lumbar & lumbosacral region
• Muscle spasm of back
• Contusion of lower back
• Abnormal reflex
• Unspecified superficial injury of lower back

Note: This is not a complete list.

Exclusions/Red Flag Conditions

Sometimes, imaging may be necessary for LBP. The following “red flag” conditions suggest a more serious underlying issue and may warrant imaging. These conditions would exclude the member from the HEDIS LBP measure:

• Cancer
• Recent trauma/fractures
• IV drug abuse (past 12 months)
• Neurologic impairment (past 12 months)
• HIV
• Spinal infection (past 12 months)
• Kidney/major organ transplant
• Prolonged corticosteroid use (90 days within past 12 months)
• Osteoporosis medication therapy
• History of lumbar surgeries
• Spondylopathy
• Recent uncomplicated LBP (past 6 months)

What Can Providers Do to Improve HEDIS Scores?

HEDIS measures the level of quality care provided by physicians and health plans. Here are some tips for meeting or exceeding the requirements of the HEDIS measure for LBP:

• Avoid ordering diagnostic studies within 28 days of diagnosis for a new onset of uncomplicated LBP when there are no “red flags.”
• Document in the medical record all findings and submit correct primary diagnosis code. Use exclusionary codes if applicable to justify if imaging is warranted.
• Provide patient education on conservative treatments.
• Use of non-steroidal anti-inflammatory drugs (NSAIDs) and, if appropriate, muscle relaxers.
• Exercise to strengthen the core and low back.
• Move and be active to limit muscle stiffening.
• Place pillow between legs while resting or sleeping (if sleeping on side), or under knees when sleeping on back to reduce back discomfort.

*HEDIS^® — an acronym for Healthcare Effectiveness Data and Information Set — is a registered trademark of NCQA.

Highmark does not recommend particular treatments or health care services. This information is not intended to be a substitute for professional medical advice, diagnosis, or treatment. You should determine the appropriate treatment and follow-up with your patient. Coverage of services is subject to the terms of each member’s benefit plan. Additionally, state laws and regulations governing health insurance, health plans and coverage may apply and will vary from state to state.