April 21, 2022 Network in the Know

Exclusions to the HEDIS Low Back Pain measure

In our ongoing effort to improve overall performance with the HEDIS Low Back Pain (LBP) measure, CDPHP is sharing information on measure exclusions. What this means is if the following condition is appropriate to your patient and coded as such, the member would be excluded and not count against your overall performance.

Exclude members who meet any of the following criteria

Cancer. Cancer any time during member’s history through 28 days after the Index Episode Start Date (IESD). Any of the following meet criteria:

  • Malignant/Non-malignant neoplasms or history of diagnosis
  • Other malignant neoplasm of skin diagnosis

Recent trauma. Trauma any time during the three months (90 days) prior to the IESD through 28 days after the IESD.

Intravenous drug abuse. IV drug abuse any time during the 12 months (one year) prior to the IESD through 28 days after the IESD.

Neurologic impairment. Neurologic impairment any time during the 12 months (one year) prior to the IESD through 28 days after the IESD.

HIV. HIV any time during member’s history through 28 days after the IESD.

Spinal infection. Spinal infection any time during the 12 months (one year) prior to the IESD through 28 days after the IESD.

Major organ transplant. Major organ transplant.

Prolonged use of corticosteroids. 90 consecutive days of corticosteroid treatment any time during the 366-day period that begins 365 days prior to the IESD and ends on the IESD.

To identify consecutive treatment days, identify calendar days covered by neurologic impairment. Neurologic impairment any time during the 12 months (one year) prior to the IESD through 28 days after the IESD.

Osteoporosis. Osteoporosis therapy or a dispensed prescription to treat osteoporosis (Osteoporosis Medication List) any time during the 12 months (one year) prior to the IESD through 28 days after the IESD.

Lumbar surgery. Lumbar surgeryany time during the member’s history through 28 days after the IESD.

Spondylopathy. Spondylopathy at any time.

Palliative care. Members receiving palliative care during the measurement year.

Members in hospice or using hospice services anytime during the measurement year.

Peter Vellis
About the Author

Peter A. Vellis, DO, joined CDPHP in February 2015 as medical director. In this role, Dr. Vellis assists in the utilization management programs and the CDPHP Enhanced Primary Care initiative. Dr. Vellis received his medical degree from the University of New England College of Osteopathic Medicine. He completed his residency in family medicine and a primary care sports medicine fellowship at Albany Medical Center. Dr. Vellis is board certified in family medicine with a CAQ (Certificate of Added Qualification) in sports medicine.

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