Decoding MIPS in Emergency Medicine – Radiology Edition

In our last edition, we discussed some ways of altering practice models or properly documenting patient care so that we stay within the current MIPS guidelines while continuing to provide the highest quality care.  In this edition, we will discuss some of the MIPS guidelines as they pertain to Radiographic studies that are commonly ordered in ER/Urgent Care settings. As always, appropriate documentation as to why, or why not, a test was ordered is crucial not only for MIPS, but from a legal standpoint as well.  So, let’s get into it!

Measure #254

           The first measure today is– Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain.  This measure is looking for the percentage of pregnant female patients aged 14-50 who present to the Emergency Department with complaints of abdominal pain or vaginal bleeding who receive a pregnancy related ultrasound, either transabdominal or transvaginal, to determine intrauterine pregnancy vs. ectopic pregnancy.  Obviously, it is best practice to make sure that the woman whom you are treating for abdominal pain or vaginal bleeding in the setting of pregnancy does indeed have an intrauterine pregnancy, so please order the appropriate test. Not ordering the test not only puts you at risk for MIPS fallout, but also for potential legal liability should the patient have an ectopic pregnancy.  The measure does state, however, that if you can document why you do not need to order the study, i.e. patient has been seen numerous times for this complaint during this pregnancy or in the past 72 hours, or has previous US documenting an intrauterine pregnancy, then this case will be excluded from the measure. Again, the key word here is documentation!

Measure #333

           Next, we will start discussing appropriate ordering of CT scans, first with measure #333 – Adult Sinusitis: Computerized Tomography for Acute Sinusitis (Overuse).   The measure is looking for the number of patients who are diagnosed with acute sinusitis who receive a CT scan of the sinuses at the time of diagnosis, or within 28 days after the diagnosis.  In the past, many practitioners felt that ordering a CT of the sinuses to evaluate for acute sinusitis was a way to ensure appropriate treatment. This led to overuse of CT for this, and an abundance of unnecessary radiation and cost to the patients.  So, if you feel that someone has an acute sinusitis, recurrent or not, treat them with appropriate medications first, and if no improvement after 28 days, then you may offer CT scan. Better yet, if the patient has had persistent acute sinusitis for greater than 28 days, refer them to ENT for evaluation.  Often the ENT physician will be able to directly visualize the sinuses in the office and avoid any radiation. And if the ENT feels it is appropriate, they can then order the study that they prefer. Obviously, if you truly feel that a CT scan of the sinuses is appropriate within that 28 day window, please order the test but be sure to document why you feel it is appropriate so that you remain in compliance with the MIPS standard.

Measure #415

           The next two measures we will discuss involve head CTs in the setting of minor blunt head trauma.  First is – Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older.  This measure is looking at the appropriate use of CT scans for blunt head trauma, and MIPS uses the definition of minor blunt trauma that only includes non-penetrating trauma.  We all know that patients who hit their head come to the ER/Urgent Care wanting a CT scan “just to be sure”, however many of them do not need this. The current recommendation is that a patient with a history of blunt head trauma who presents with the following symptoms should receive a non-contrast CT of the head:

Patients with any one of the following:

• GCS score less than 15
• Severe headache
• Vomiting
• Age 65 years and older
• Physical signs of a basilar skull fracture (signs include hemotympanum, “raccoon” eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign
• Focal neurological deficit
• Coagulopathy
• Thrombocytopenia
• Currently taking any anticoagulant medications
• Dangerous mechanism of injury (i.e., ejection from a motor vehicle, a pedestrian struck, and a fall from a height of more than 3 feet or 5 stairs)

OR

Patients with either loss of consciousness OR post-traumatic amnesia AND any one of the following:

• GCS score less than 15
• Headache
• Age 60 years and older, and less than 65 years
• Drug/alcohol intoxication
• Short-term memory deficits
• Evidence of trauma above the clavicles (physical location, any trauma to the head or neck [i.e., laceration, abrasion, bruising, ecchymosis, hematoma, swelling, fracture])
• Post-traumatic seizure

           Patients excluded from this measure are ones with a history of brain tumor, ventricular shunt, or coagulopathy.  As you can see, many of the patients we see for minor blunt head trauma will not meet these criteria, and therefore should not receive a CT scan of the head.  However, there are always patients who insist so the best you can do is document your discussion with the patient as to why they do not need a CT at this time and if they continue to insist, document this too and then order the test.

Measure #416

           Similarly, measure #416 – Emergency Department Utilization for CT for Minor Blunt Head Trauma for Patients aged 2 through 17 Years. This standard looks at overuse of head CTs in children with minor blunt head trauma, but uses the PECARN (Pediatric Emergency Care Applied Research Network) prediction rules for traumatic brain injury.  Note that this is for patients age 2-17, and patients who are under the age of 2 with blunt head trauma should have a CT scan to rule out injury and are not subject to the PECARN rules. According to PECARN prediction rules, patients can be classified as low risk for traumatic brain injury if all of the following criteria are met:

• No signs of altered mental status (e.g., agitation, somnolence, repetitive questioning, slow response to verbal communication)
• No signs of basilar skull fracture (signs include hemotympanum, “raccoon” eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
• No loss of consciousness
• No vomiting
• No severe mechanism of injury (i.e., motor vehicle crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle; falls of more than 5 feet; or head struck by a high-impact object)
• No severe headache
• No GCS < 15

Ideally, for this measure, you want to have as close to 0% of patients who are PECARN negative to get a CT head for minor blunt trauma.  Obviously, if you cannot rule out minor head injury using PECARN, or the family is insistent on a CT scan, then please make sure that you document carefully and order the appropriate test.

Closing

MIPS measures can be confusing, but hopefully this will help you navigate some of the pitfalls and help make sure that not only are you “in compliance”, but are also providing the highest quality of care while placing the patient’s safety and wellbeing at the forefront.