Guidelines for Imaging in Low Back Pain

Blue Cross and Blue Shield have made policy changes in reference to imaging for lower back pain as highlighted below. Note for chiropractic claims there is indication of no routine films in absence of trauma. I would also note red flag symptoms and if patient is over 50. But please be aware that we must always be able to justify the need for x-ray if questioned.

Healthcare Effectiveness Data and Information Set (HEDIS®) was developed and is maintained by the National Committee for Quality Assurance (NCQA) to standardize and measure quality for all patients. The Office of Personnel Management (OPM) reviews HEDIS performance of certain measures for Federal Employee Program® (FEP®) members. One of these measures looks at the appropriate use of all diagnostic imaging studies, including x-rays, for uncomplicated new onset lower back pain.

Generally, patients with new onset low back pain diagnosis should not receive any imaging within the first 28 days of diagnosis, but rather receive conservative medical treatment with prescription strength analgesics and physical therapy.

NCQA realizes that each patient’s presentation is unique, and imaging may be required, and has therefore added a vast number of medical conditions where imaging could be considered medically necessary on initial patient presentation. Providing the additional diagnosis in your medical evaluation when such situations present exclude such patients from your HEDIS metric.

For information purposes only, the chart below outlines some such additional diagnoses that may present during a low back pain patient visit.

DESCRIPTION ICD-10 CODE
Cancer (active) All ICD-10 “C” codes
Cancer (personal history) All ICD-10 “Z” codes
HIV B20; Z21
IV drug abuse All ICD-10 “F” codes
Kidney transplant 0TY00Z0-0TY00Z2; 0TY10Z0-0TY10Z2
Major organ transplant, other than kidney Heart, small intestine, large intestine, liver, pancreas islets, ovaries, face, head, thymus, spleen, lungs, esophagus, stomach
Neurologic impairment G83.4
Spinal infection, osteomyelitis, and discitis A17.81, G06.1, M46.25-M46.28, M46.35-M46.38, M46.46-M46.48
Trauma/fractures All ICD-10 “S” codes

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