Measure: CMS249
Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture
Measure Versions
| eMeasure Code |
Measure Year |
Full Version Number |
Title |
| CMS249v6 |
2024 |
6.0.000 |
Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture |
| CMS249v5 |
2023 |
5 |
Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture |
| CMS249v4 |
2022 |
4.0.000 |
Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture |
| CMS249v3 |
2021 |
3.2.000 |
Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture |
| CMS249v2 |
2020 |
2.4.000 |
Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture |
| CMS249v1 |
2019 |
1.4.000 |
Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture |
Description
Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period.
Guidance
CUMULATIVE MEDICATION DURATION is an individual's total number of medication days over a specific period; the period counts multiple prescriptions with gaps in between, but does not count the gaps during which a medication was not dispensed.
To determine the cumulative medication duration, determine first the number of the Medication Days for each prescription in the period: the number of doses divided by the dose frequency per day. Then add the Medication Days for each prescription without counting any days between the prescriptions.
For example, there is an original prescription for 30 days with 2 refills for thirty days each. After a gap of 3 months, the medication was prescribed again for 60 days with 1 refill for 60 days. The cumulative medication duration is (30 x 3) + (60 x 2) = 210 days over the 10 month period.
There are two ways that a patient can be excluded from the measure:
1. The patient has a specific number of "combination" risk factors (the number of risk factors varies by age).
2. The patient has one or more of the "independent" risk factors, including a 10-year probability of major osteoporotic fracture of 9.3 percent or higher as determined by the FRAX.
Patient Group Definitions
| Group |
Description |
Instructions Links |
| Initial Population | Female patients ages 50 to 64 years with an encounter during the measurement period | Webchart Instructions |
| Denominator | Equals Initial Population | Webchart Instructions |
| Denominator Exclusions | Exclude patients with a combination of risk factors (as determined by age) or one of the independent risk factors
Ages: 50-54 (>=4 combination risk factors) or 1 independent risk factor
Ages: 55-59 (>=3 combination risk factors) or 1 independent risk factor
Ages: 60-64 (>=2 combination risk factors) or 1 independent risk factor
COMBINATION RISK FACTORS [The following risk factors are all combination risk factors; they are grouped by when they occur in relation to the measurement period]:
The following risk factors may occur any time in the patient's history but must be active during the measurement period:
White (race)
BMI <= 20 kg/m2 (must be the first BMI of the measurement period)
Smoker (current during the measurement period)
Alcohol consumption (> two units per day (one unit is 12 oz. of beer, 4 oz. of wine, or 1 oz. of liquor))
The following risk factor may occur any time in the patient's history and must not start during the measurement period:
Osteopenia
The following risk factors may occur at any time in the patient's history or during the measurement period:
Rheumatoid arthritis
Hyperthyroidism
Malabsorption Syndromes: celiac disease, inflammatory bowel disease, ulcerative colitis, Crohn's disease, cystic fibrosis, malabsorption
Chronic liver disease
Chronic malnutrition
Documentation of history of hip fracture in parent
Osteoporotic fracture
Glucocorticoids (>= 5 mg/per day) [cumulative medication duration >= 90 days]
INDEPENDENT RISK FACTORS (The following risk factors are all independent risk factors; they are grouped by when they occur in relation to the measurement period):
The following risk factors may occur at any time in the patient's history and must not start during the measurement period:
Osteoporosis
The following risk factors may occur at any time in the patient's history:
Gastric bypass
FRAX[R] ten-year probability of all major osteoporosis related fracture >= 9.3 percent
Aromatase inhibitors
Type I Diabetes
End stage renal disease
Osteogenesis imperfecta
Ankylosing spondylitis
Psoriatic arthritis
Ehlers-Danlos syndrome
Cushing's syndrome
Hyperparathyroidism
Marfan syndrome
Lupus | Webchart Instructions |
| Numerator | Female patients who received an order for at least one DXA scan in the measurement period | Webchart Instructions |
| Numerator Exclusions | Not Applicable | Webchart Instructions |
| Denominator Exceptions | None | |
Details
| Full eMeasure Code |
eMeasure Identifier |
Measure Year |
Version |
NQF # |
GUID |
| CMS249v1 |
249 |
2019 |
1.4.000 |
Not Applicable |
A3CE125D-C238-42CE-862E-DBA0055DFC66 |
| Steward |
Developer |
Endorsed By |
| National Committee for Quality Assurance |
Centers for Medicare & Medicaid Services (CMS) |
|
| Scoring Method |
Measure Type |
Stratification |
Risk Adjustment |
| Proportion |
PROCESS |
None |
None |
Rate Aggregation
None
Improvement Notation
Lower score indicates better quality
Rationale
This measure is expected to increase recording of patient risk for fracture data and decrease the amount of inappropriate DXA scans. Current osteoporosis guidelines underscore the importance of screening women for osteoporosis if they are 1) 65 years or older or 2) younger than 65 if they have a fracture risk "equal to or greater than that of a 65-year-old white woman who has no additional risk factors." Clinical information, such as age, body mass index (BMI), parental fracture history, and tobacco and alcohol use, can be used to determine a woman's fracture risk (USPSTF, 2011). Additionally, there are potentially avoidable harms associated with screening for osteoporosis in general, including exposure to radiation, false positive exams, and resulting side effects from unnecessary osteoporosis medications, which add costs to an already burdened health care system (Lim, 2009).
Clinical Recommendation Statement
United States Preventive Services Task Force (USPSTF):
"The USPSTF recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. This is a B recommendation."
"The USPSTF concludes that for men, evidence of the benefits of screening for osteoporosis is lacking and the balance of benefits and harms cannot be determined."
"The USPSTF used the FRAX (Fracture Risk Assessment) tool to estimate a 10-year risk for fractures because this tool relies on easily obtainable clinical information, such as age, body mass index (BMI), parental fracture history, and tobacco and alcohol use; its development was supported by a broad international collaboration and extensively validated in 2 large U.S. cohorts; and it is freely available to clinicians and the public."
"On the basis of the U.S. FRAX tool, a 65-year-old white woman with no other risk factors has a 9.3% 10-year risk for any osteoporotic fracture. White women aged 50 to 64 years with equivalent or greater 10-year fracture risks based on specific risk factors include but are not limited to the following persons: 1) a 50-year-old current smoker with a BMI less than 21 kg/m2, daily alcohol use, and parental fracture history; 2) a 55-year-old woman with parental fracture history; 3) a 60-year-old woman with a BMI less than 21 kg/m2 and daily alcohol use; and 4) a 60-year old current smoker with daily alcohol use. The FRAX tool also predicts 10-year fracture risks for black, Asian, and Hispanic women in the United States. In general, estimated fracture risks in nonwhite women are lower than those for white women of the same age."
The National Institute for Health and Clinical Excellence (NICE) Osteoporosis Guidelines:
"Consider assessment of fracture risk:
a. in all women aged 65 years and over and all men aged 75 years and over
b. in women aged under 65 years and men aged under 75 years in the presence of risk factors, for
example:
*previous fragility fracture
*current use or frequent/ recent use of oral or systemic glucocorticoids
*history of falls
*family history of hip fracture
*other causes of secondary osteoporosis
*low body mass index (BMI) (less than 18.5 kg/m2)
*smoking
*alcohol intake of more than 14 units per week for women and more than 21 units per week for men."
"Do not routinely assess fracture risk in people aged under 50 years unless they have major risk
factors (for example, current or frequent/recent use of oral or systemic glucocorticoids, untreated
premature menopause or previous fragility fracture), because they are unlikely to be at high risk."
"Estimate absolute risk when assessing risk of fracture (for example, the predicted risk of major osteoporotic or hip fracture over 10 years, expressed as a percentage."
"Use either FRAX (without a bone mineral density [BMD] value if a dual energy X-ray absorptiometry [DXA] scan has not previously been undertaken) or QFracture, within their allowed age ranges, to estimate 10-year predicted absolute fracture risk when assessing risk of fracture."
"Do not routinely measure BMD to assess fracture risk without prior assessment using FRAX
(without a BMD value) or QFracture."
"Take into account that risk assessment tools may underestimate fracture risk in certain
circumstances, for example if a person:
*has a history of multiple fractures
*has had previous vertebral fracture(s)
*has a high alcohol intake
*is taking high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone
or equivalent per day for 3 months or longer)
*has other causes of secondary osteoporosis."
Definition
The measure allows for providers to use the Fracture Risk Assessment Tool (FRAX[R]) to calculate 10-year absolute fracture risk. The FRAX was developed by the World Health Organization in 2008 to evaluate a patient's 10-year probability of hip fracture and major osteoporotic fracture (clinical spine, forearm, hip, or shoulder fracture). It is applicable to people aged 40-90 years.
Transmission Format
TBD
Applicable Value Sets
| Category |
Value Set |
OID |
| Assessment, Performed |
|
2.16.840.1.113883.3.464.1003.118.12.1081 |
| Assessment, Performed |
Average Number of Drinks per Drinking Day |
2.16.840.1.113883.3.464.1003.106.12.1018 |
| Assessment, Performed |
History of hip fracture in parent |
2.16.840.1.113883.3.464.1003.113.12.1040 |
| Assessment, Performed |
Tobacco Use Screening |
2.16.840.1.113883.3.526.3.1278 |
| Diagnosis |
Ankylosing Spondylitis |
2.16.840.1.113883.3.464.1003.113.12.1045 |
| Diagnosis |
Chronic Liver Disease |
2.16.840.1.113883.3.464.1003.199.12.1035 |
| Diagnosis |
Chronic Malnutrition |
2.16.840.1.113883.3.464.1003.199.12.1036 |
| Diagnosis |
Cushings Syndrome |
2.16.840.1.113883.3.464.1003.117.12.1009 |
| Diagnosis |
Ehlers Danlos Syndrome |
2.16.840.1.113883.3.464.1003.113.12.1047 |
| Diagnosis |
End Stage Renal Disease |
2.16.840.1.113883.3.526.3.353 |
| Diagnosis |
Hyperparathyroidism |
2.16.840.1.113883.3.464.1003.117.12.1016 |
| Diagnosis |
Hyperthyroidism |
2.16.840.1.113883.3.464.1003.117.12.1015 |
| Diagnosis |
Lupus |
2.16.840.1.113883.3.464.1003.117.12.1010 |
| Diagnosis |
Malabsorption Syndromes |
2.16.840.1.113883.3.464.1003.199.12.1050 |
| Diagnosis |
Marfan's Syndrome |
2.16.840.1.113883.3.464.1003.113.12.1048 |
| Diagnosis |
Osteogenesis Imperfecta |
2.16.840.1.113883.3.464.1003.113.12.1044 |
| Diagnosis |
Osteopenia |
2.16.840.1.113883.3.464.1003.113.12.1049 |
| Diagnosis |
Osteoporosis |
2.16.840.1.113883.3.464.1003.113.12.1038 |
| Diagnosis |
Osteoporotic Fractures |
2.16.840.1.113883.3.464.1003.113.12.1050 |
| Diagnosis |
Psoriatic Arthritis |
2.16.840.1.113883.3.464.1003.113.12.1046 |
| Diagnosis |
Rheumatoid Arthritis |
2.16.840.1.113883.3.464.1003.113.12.1005 |
| Diagnosis |
Type 1 Diabetes |
2.16.840.1.113883.3.464.1003.103.12.1020 |
| Diagnostic Study, Order |
DXA (Dual energy Xray Absorptiometry) Scan |
2.16.840.1.113883.3.464.1003.113.12.1051 |
| Encounter, Performed |
Office Visit |
2.16.840.1.113883.3.464.1003.101.12.1001 |
| Encounter, Performed |
Outpatient Consultation |
2.16.840.1.113883.3.464.1003.101.12.1008 |
| Encounter, Performed |
Preventive Care Services - Established Office Visit, 18 and Up |
2.16.840.1.113883.3.464.1003.101.12.1025 |
| Encounter, Performed |
Preventive Care Services - Other |
2.16.840.1.113883.3.464.1003.101.12.1030 |
| Encounter, Performed |
Preventive Care Services-Initial Office Visit, 18 and Up |
2.16.840.1.113883.3.464.1003.101.12.1023 |
| Medication, Active |
Aromatase Inhibitors |
2.16.840.1.113883.3.464.1003.196.12.1265 |
| Medication, Active |
Glucocorticoids (oral only) |
2.16.840.1.113883.3.464.1003.196.12.1266 |
| Medication, Order |
Aromatase Inhibitors |
2.16.840.1.113883.3.464.1003.196.12.1265 |
| Patient Characteristic Ethnicity |
Ethnicity |
2.16.840.1.114222.4.11.837 |
| Patient Characteristic Payer |
Payer |
2.16.840.1.114222.4.11.3591 |
| Patient Characteristic Race |
Race |
2.16.840.1.114222.4.11.836 |
| Patient Characteristic Race |
White |
2.16.840.1.113883.3.464.1003.123.12.1007 |
| Patient Characteristic Sex |
Female |
2.16.840.1.113883.3.560.100.2 |
| Patient Characteristic Sex |
ONC Administrative Sex |
2.16.840.1.113762.1.4.1 |
| Physical Exam, Performed |
BMI Ratio |
2.16.840.1.113883.3.600.1.1490 |
| Procedure, Performed |
Gastric Bypass Surgery |
2.16.840.1.113883.3.464.1003.198.12.1050 |
References
U.S. Preventive Services Task Force (USPSTF). "Screening for Osteoporosis in Postmenopausal Women." Rockville, MD: AHRQ, January 2011. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspsoste.htm. Accessed February 10, 2018.
Lim, L. S., L. J. Hoeksema, and K. Sherin. "Screening for Osteoporosis in the Adult U.S. Population. ACPM Position Statement on Preventive Practice." American Journal of Preventive Medicine, vol. 36, no. 4, 2009, pp. 366-75.
National Institute for Health and Clinical Excellence (NICE). Osteoporosis: Fragility Fracture Risk. 2012. Available at [https://www.nice.org.uk/guidance/cg146/chapter/1-Guidance]. Accessed February 10, 2018.
Disclaimer
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Copyright
This Physician Performance Measure (Measure) and related data specifications are owned and were developed by the National Committee for Quality Assurance (NCQA) under contract with the Centers for Medicare and Medicaid Services (CMS) (Contract No. HHSM-500-2013-13011I, Task No. HHSM-500-TO001). NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in the Measure. The Measure can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. (C) 2012-2017 National Committee for Quality Assurance. All Rights Reserved.
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Source:
https://ecqi.healthit.gov/ecqm/measures/cms249v1