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Measure #195 (NQF 0507): Radiology: Stenosis Measurement in Carotid Imaging Reports – NationalQuality Strategy Domain: Effective Clinical Care2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES:CLAIMS, REGISTRYDESCRIPTION:Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computedtomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirectreference to measurements of distal internal carotid diameter as the denominator for stenosis measurementINSTRUCTIONS:This measure is to be reported each time a carotid imaging study is performed during the reporting period for allpatients, regardless of age. There is no diagnosis associated with this measure. Clinicians who provide theprofessional component of diagnostic imaging studies of the carotids will submit this measure.Measure Reporting via Claims:CPT codes are used to identify patients who are included in the measure’s denominator. CPT Category II codes areused to report the numerator of the measure.When reporting the measure via claims, submit the listed CPT procedure codes and the appropriate CPT Category IIcode OR the CPT Category II code with the modifier. The reporting modifier allowed for this measure is: 8P- reasonnot otherwise specified. There are no allowable performance exclusions for this measure. All measure-specificcoding should be reporting on the claim(s) representing the eligible encounter.Measure Reporting via Registry:CPT codes are used to identify patients who are included in the measure’s denominator. The listed numeratoroptions are used to report the numerator of the measure.The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes maybe submitted for those registries that utilize claims data. There are no allowable performance exclusions for thismeasure.DENOMINATOR:All final reports for carotid imaging studies (neck MR angiography [MRA], neck CT angiography [CTA], neck duplexultrasound, carotid angiogram) performedDenominator Criteria (Eligible Cases):Patient encounter during the reporting period (CPT): 36222, 70498, 70547, 70548, 70549, 93880,93882NUMERATOR:Final reports for carotid imaging studies that include direct or indirect reference to measurements of distal internalcarotid diameter as the denominator for stenosis measurementNumerator Instructions: This measure requires that the estimate of stenosis included in the report of theimaging study employ a method such as the North American Symptomatic Carotid Endarterectomy Trial(NASCET) method for calculating the degree of stenosis. The NASCET method calculates the degree ofstenosis with reference to the lumen of the carotid artery distal to the stenosis.For duplex imaging studies the reference is indirect, since the degree of stenosis is inferred from velocityparameters and cross referenced to published or self-generated correlations among velocity parametersVersion 10.011/17/2015CPT only copyright 2015 American Medical Association. All rights reserved.Page 1 of 6

and results of angiography or other imaging studies which serve as the gold standard. In Dopplerultrasound, the degree of stenosis can be estimated using Doppler parameter of the peak systolic velocity(PSV) of the internal carotid artery (ICA), with concordance of the degree of narrowing of the ICA lumen.Additional Doppler parameters of ICA-to-common carotid artery (CCA) PSV ratio and ICA end-diastolicvelocity (EDV) can be used when degree of stenosis is uncertain from ICA PSV. (Grant et al, 2003)A short note can be made in the final report, such as:Severe left ICA stenosis of 70-80% by NASCET criteria” or“Severe left ICA stenosis of 70-80% by criteria similar to NASCET” or“70% stenosis derived by comparing the narrowest segment with the distal luminal diameter as related tothe reported measure of arterial narrowing” or“Severe stenosis of 70-80% - validated velocity measurements with angiographic measurements, velocitycriteria are extrapolated from diameter data as defined by the Society of Radiologists in UltrasoundConsensus Conference Radiology 2003; 229;340-346”.Definition:“Direct or indirect reference to measurements of distal internal carotid diameter as the denominatorfor stenosis measurement” – includes direct angiographic stenosis calculation based on the distal lumenas the denominator for stenosis measurement OR an equivalent validated method referenced to the abovemethod (e.g., for duplex ultrasound studies, velocity parameters that correlate with anatomicmeasurements that use the distal internal carotid lumen as the denominator for stenosis measurement).ORNumerator Quality-Data Coding Options for Reporting Satisfactorily:Reference to Measurements of Distal Internal Carotid Diameter as the Denominator for StenosisMeasurement ReferencedPerformance Met: CPT II 3100F:Carotid imaging study report (includes direct or indirectreference to measurements of distal internal carotiddiameter as the denominator for stenosis measurement)Measurements of Distal Internal Carotid Diameter not Referenced, Reason not Otherwise SpecifiedAppend a reporting modifier (8P) to CPT Category II code 3100F to report circumstances when the actiondescribed in the numerator is not performed and the reason is not otherwise specified.Performance Not Met: 3100F with 8P:Carotid imaging study report did not include direct orindirect reference to measurements of distal internalcarotid diameter as the denominator for stenosismeasurement, reason not otherwise specifiedRATIONALE:Accurate assessment of the degree of carotid artery stenosis is essential to guiding proper treatment decisions forpatients with carotid artery disease. Trials have demonstrated the ability of the degree of carotid artery stenosis topredict which patients will receive the greatest benefit from surgical intervention. To ensure accurate assessment ofstenosis, it is important to use a standardized, validated approach. Rothwell et al demonstrated significant differencesbetween measurements of stenosis made using different methods of measurement.CLINICAL RECOMMENDATION STATEMENTS:The panel recommended that the NASCET method of carotid stenosis measurement should be used whenangiography is used to correlate the US findings. (SRU, 2003)When MRA techniques are used for determining carotid stenosis, the report should reflect the methodology andreference the criteria for percent stenosis outlined in the NASCET. Also, the percent stenosis must be calculatedusing the distal cervical ICA diameter, where the walls are parallel, for the denominator. Similar to CTA, MRA withattention to the acquisition parameters and post-processing techniques can provide cross sectional measurements ofVersion 10.011/17/2015CPT only copyright 2015 American Medical Association. All rights reserved.Page 2 of 6

stenosis that correlate with properly performed NASCET estimates of percent stenosis obtained with catheterangiography. In the setting of near occlusion, it may not be accurate to calculate percent stenosis ratios in thepresence of post-stenotic arterial diameter decrease. Some MRA techniques may not be amenable to quantitativemeasurements, in which case qualitative assessment of stenosis should be provided. (ACR, 2010)COPYRIGHT:The Measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested forall potential applications.The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercialpurposes, eg, use by health care providers in connection with their practices. Commercial use is defined as the sale,license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product orservice that is sold, licensed or distributed for commercial gain.Commercial uses of the Measures require a license agreement between the user and the American MedicalAssociation (AMA), [on behalf of the Physician Consortium for Performance Improvement (PCPI )] orAmerican College of Radiology (ACR). Neither the AMA, ACR, PCPI, nor its members shall be responsible forany use of the Measures.The AMA’s, PCPI’s and National Committee for Quality Assurance’s significant past efforts and contributions to thedevelopment and updating of the Measures is acknowledged. ACR is solely responsible for the review andenhancement (“Maintenance”) of the Measures as of December 31, 2014.ACR encourages use of the Measures by other health care professionals, where appropriate.THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND. 2015 American Medical Association and American College of Radiology. All Rights Reserved. ApplicableFARS/DFARS Restrictions Apply to Government Use.Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary codesets should obtain all necessary licenses from the owners of these code sets. The AMA, ACR, the PCPI and itsmembers disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT ) or other codingcontained in the specifications.CPT contained in the Measures specifications is copyright 2004-2015 American Medical Association. LOINC copyright 2004-2015 Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT ) copyright 2004-2015College of American Pathologists. All Rights Reserved.Version 10.011/17/2015CPT only copyright 2015 American Medical Association. All rights reserved.Page 3 of 6

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2016 Claims/Registry Individual Measure FlowPQRS #195 NQF #0507: Radiology: Stenosis Measurement in Carotid Imaging ReportsPlease refer to the specific section of the Measure Specification to identify the denominator and numeratorinformation for use in reporting this Individual Measure.1. Start with Denominator2. Check Encounter Performed:a. If Encounter as Listed in the Denominator equals No, do not include in Eligible Patient Population. StopProcessing.b. If Encounter as Listed in the Denominator equals Yes, include in the Eligible Population.3. Denominator Population:a. Denominator population is all Eligible Patients in the denominator. Denominator is represented asDenominator in the Sample Calculation listed at the end of this document. Letter d equals 8 procedures inthe sample calculation.4. Start Numerator5. Check Carotid Imaging Study Report (Includes Direct or Indirect Reference to Measurements of Distal InternalCarotid Diameter as the Denominator for Stenosis Measurement):a. If Carotid Imaging Study Report (Includes Direct or Indirect Reference to Measurements of Distal InternalCarotid Diameter as the Denominator for Stenosis Measurement) equals Yes, include in Reporting Metand Performance Met.b. Reporting Met and Performance Met letter is represented in the Reporting Rate and Performance Rate inthe Sample Calculation listed at the end of this document. Letter a equals 4 procedures in SampleCalculation.c. If Carotid Imaging Study Report (Includes Direct or Indirect Reference to Measurements of Distal InternalCarotid Diameter as the Denominator for Stenosis Measurement) equals No, proceed to Carotid ImagingStudy Report did Not Include Direct or Indirect Reference to Measurements of Distal Internal CarotidDiameter as the Denominator for Stenosis Measurement, Reason Not Otherwise Specified.6. Check Carotid Imaging Study Report did Not Include Direct or Indirect Reference to Measurements of DistalInternal Carotid Diameter as the Denominator for Stenosis Measurement, Reason Not Otherwise Specified:a. If Carotid Imaging Study Report did Not Include Direct or Indirect Reference to Measurements of DistalInternal Carotid Diameter as the Denominator for Stenosis Measurement, Reason Not OtherwiseSpecified equals Yes, include in Reporting Met and Performance Not Met.b. Reporting Met and Performance Not Met letter is represented in the Reporting Rate and PerformanceRate in the Sample Calculation listed at the end of this document. Letter c equals 3 procedures in theSample Calculation.c. If Carotid Imaging Study Report did Not Include Direct or Indirect Reference to Measurements of DistalInternal Carotid Diameter as the Denominator for Stenosis Measurement, Reason Not OtherwiseSpecified equals No, proceed to Reporting Not Met.Version 10.011/17/2015CPT only copyright 2015 American Medical Association. All rights reserved.Page 5 of 6

7. Check Reporting Not Met:a. If Reporting Not Met equals No, Quality Data Code or equivalent not reported. 1 procedure has beensubtracted from the reporting numerator in the sample calculation.Version 10.011/17/2015CPT only copyright 2015 American Medical Association. All rights reserved.Page 6 of 6

Measure Reporting via Claims: CPT codes are used to identify patients who are included in the measure’s denominator. CPT Category II codes are used to report the numerator of the measure. When reporting the measure via claims, submit the liste