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PQRS Update: Measure #405 for Radiology Services

Measure #405:  Appropriate Follow-up Imaging for Incidental Abdominal Lesions

The Centers for Medicare and Medicaid Services (CMS) adopted new quality measure #405 for the 2016 reporting period.  It is anticipated that clinicians who provide the professional component of diagnostic imaging studies will submit this measure.

The intent of this measure is to reduce unnecessary follow-up imaging of incidental lesions unless clinically indicated.  It applies to asymptomatic patients aged 18 years and older undergoing abdominal CT, MRI or ultrasound with incidental findings of any of the following: 

• Liver lesion  < 0.5cm
• Cystic kidney lesion  < 1.0 cm
• Adrenal lesion  < 1.0 cm

The incidental lesion(s), if found, must be documented in the radiologist’s interpretive report along with the corresponding follow-up recommendation status:
• No follow-up imaging is recommended
• Follow up imaging is recommended and the medical reason is stated (e.g., known malignancy that could metastasize)
• Follow-up imaging is recommended but no medical reason is given

As long as documentation reflects the presence of incidental lesions noted during the study as listed above, two PQRS codes are reported to CMS.  If no incidental lesions are noted, the study will be assigned a single PQRS exclusion code for the measure.  The designated PQRS codes and their respective applications are summarized below.

Final reports with follow-up imaging recommended

G9548   Performance Met/Final reports for abdominal imaging with follow-up imaging recommended     AND

G9547   Incidental finding:  liver lesion .5 cm or less; cystic kidney lesion less than 1.0 cm or adrenal lesion 1.0 cm or less

Documenting medical reason(s) for recommended follow-up

G9549   Medical Performance Exclusion/Final reports reflect the medical reason(s) that follow-up imaging is indicated     AND

G9547   Incidental finding:  liver lesion .5 cm or less; cystic kidney lesion less than 1.0 cm or adrenal lesion 1.0 cm or less

Final report without incidental finding G9551   Other Performance Exclusion/final reports for abdominal imaging studies without mention of lever lesion .5 cm or less, cystic kidney lesion less than 1.0 cm or adrenal lesion 1.0 cm or less
Final reports with follow-up imaging not recommended

G9550   Performance not met/final reports for abdominal studies with follow-up imaging not recommended     AND

G9547   Incidental finding:  liver lesion .5 cm or less; cystic kidney lesion less than 1.0 cm or adrenal lesion 1.0 cm or less

Note that, unlike most other PQRS measures where a higher performance rate is the goal, #405 is referred to as an Inverse Measure, meaning a lower calculated performance rate (G9548) indicates better care or control. 

The following imaging studies apply to this PQRS measure. There are no associated diagnosis requirements.

74150   CT Abdomen without contrast
74160   CT abdomen with contrast
74170   CT Abdomen without contrast followed by contrast and further sections
74176   CT abdomen and pelvis without contrast
74177   CT abdomen and pelvis with contrast
74178   CT abdomen and pelvis without contrast in one or both body regions followed by contrast and further sections in one or both body regions
74181   MRI abdomen without contrast
74182   MRI abdomen with contrast
74183   MRI abdomen without contrast followed by contrast and further sequences
76700   Ultrasound abdomen real time with image documentation, complete
76705   Ultrasound abdomen real time with image documentation, limited (ie, single organ, quadrant, follow-up)
76770   Ultrasound retroperitoneal (ie, renal, aorta, nodes), real time with image documentation, complete
76775   Ultrasound retroperitoneal (ie, renal, aorta, nodes), real time with image documentation, limited

In keeping with the specifications of this measure, APS coding personnel will assign the applicable PQRS code(s) at the time of coding processing, based on the documentation within the final interpretive reports. 

The full details of Measure # 405 can be downloaded at:
https://pqrs.cms.gov/dataset/2016-PQRS-Measure-405-11-17-2015/csxt-yhsv

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