Imaging for Low Back Pain

The National Commission for Quality Assurance (NCQA) maintains quality and performance standards for certain conditions, including, but not limited to, the use of imaging studies for patients with a primary diagnosis of uncomplicated low back pain.

Health plans, including BCBSNC, are expected to ensure compliance to these standards. Because you are a participating provider with BCBSNC, you are required to comply with these same standards.

Effective January 1, 2022, the NCQA Standard relating to imaging for LBP states that for patients between the ages of 18-75 with a primary diagnosis of low back pain, in the absence of certain red flags, imaging studies within 28 days of the initial diagnosis of low back pain are not considered clinically appropriate. HNS has confirmed that this standard is not specific to chiropractic. It applies to all health care providers, including, but not limited to, physicians, mid-level providers, hospitals, emergency departments, urgent care centers, etc. 

Note: The 28 days begins on the date the provider first diagnoses the patient with low back pain.

Red Flags:

If the patient presents with one of the following "red flags", imaging studies within the first 28 days of the low back pain diagnosis are considered clinically appropriate:

• Cancer
  
• Recent Trauma
  
• IV Drug Abuse
  
• Neurologic Impairment
  
• HIV
  
• Spinal Infection
  
• Major Organ Transplant
  
• Prolonged Use of Corticosteroids
  
• Osteoporosis
  
• Fragility Fracture
  
• Lumbar Surgery
  
• Spondylopathy
  
• Palliative Care
  
• Hospice
  
• Frailty and Advance Illness (must have both; applies to patients 66 years of age and older)
  
• Malignant Neoplasm
  
• History of Malignant Neoplasm
  
• Other Neoplasms
  
• IV Drug Use

The quality measure that limits imaging applies IF the patient's primary diagnosis is low back pain. These low back pain diagnoses include, but are not limited to, the diagnoses listed below:

• Low back pain
  
• Segmental and somatic dysfunction of lumbar region
  
• Segmental and somatic dysfunction of sacral region
  
• Radiculopathy, lumbar region
  
• Radiculopathy, lumbosacral region
  
• Lumbago with sciatica, left side
  
• Lumbago with sciatica, right side
  
• Intervertebral disc disorder with radiculopathy, lumbosacral region
  
• Other intervertebral disc displacement, lumbar region
  
• Other intervertebral disc degeneration, lumbar region
  
• Other intervertebral disc degeneration, lumbosacral region
  
• Spondylosis without myelopathy or radiculopathy, lumbar region
  
• Spondylosis without myelopathy or radiculopathy, lumbosacral region
  
• Sprain of ligaments of lumbar spine, initial encounter

Unfortunately, the NCQA limits the publication of these "red flag" diagnoses to any format other than as provided by HNS. Providers will need to find the applicable "red flag" category, then scroll through the diagnoses associated with that category to determine if imaging is allowed as a result of one of the red flags.

HNS recognizes that 1) many of these codes will not be relevant to your patients and 2) the inability to modify the list of codes makes it quite difficult to determine if a red flag is present. However, as noted above, HNS is not permitted to alter/modify this list in any way.

Non-Covered Service Waiver: If you need x-rays on a patient but those x-rays are not consistent with the above NCQA Standard, please first have the patient sign a non-covered service waiver agreeing to pay for the x-rays, and be sure to keep the waiver on file in the patient's healthcare record. 

Click here for the list of ICD-10 codes which

represent the "red flag" diagnoses.