Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT

Measure Specification

With the increasing use of chest computed tomography (CT) imaging comes an increase in the frequency of incidental pulmonary nodule findings. A recent study found that between 2006 and 2012, the annual rate of pulmonary nodule identification in a large, integrated health system increased from 3.9 to 6.6 per 1,000 person-years. The authors estimated that more than 1.

5 million adult Americans will have a pulmonary nodule identified each year. These incidental findings require appropriate management to avoid subjecting patients to unnecessary follow-up scans or conversely missing early malignancies. A number of factors contribute to appropriate management decisions for pulmonary nodules, based on estimations of the individual risk of malignancy including nodule size and morphology as well as clinical risk factors.

Despite evidence-based recommendations from groups such as the Fleishner society regarding the management and follow-up of small pulmonary nodules detected incidentally, various studies have documented low rates of adherence. For example, one recent study found that 44.7% of patients received care inconsistent with the Fleischner society recommendations (17.

8% overevaluation, 26.9% underevaluation). This measure aims to encourage the use of an evidence-based approach in recommending follow up imaging for incidental pulmonary nodules.

2019 Addition to Supporting Guidelines: Lung nodules are commonly encountered in the portions of the lungs that are included on CT scans of the neck, heart, and abdomen, and the question often arises as to whether a complete thoracic CT examination should be performed in such instances. For most small nodules (<6 mm), we do not recommend any further investigation on the basis of the estimated low risk of malignancy.

For intermediate-size (6–8-mm) nodules, we recommend follow-up CT of the complete chest after an appropriate interval (3–12 months depending on clinical risk) to confirm stability and to evaluate additional findings. If nodule stability can be demonstrated on the basis of retrospective comparison with a previous study, that may suffice. In the case of a large or very suspicious nodule, we recommend proceeding with a complete thoracic CT examination for further evaluation.

(MacMahon, et al., 2017) Technical update to 2018 specifications: The following evidence statements are quoted verbatim from the referenced clinical guidelines and other sources: Recommendation 1: single solid noncalcified nodules. Solid nodules smaller than 6 mm (those 5 mm or smaller) do not require routine follow-up in patients at low risk (grade 1C; strong recommendation, low- or very-low-quality evidence).

(MacMahon, et al., 2017) Solid nodules smaller than 6 mm do not require routine follow-up in all patients with high clinical risk; however, some nodules smaller than 6 mm with suspicious morphology, upper lobe location, or both may warrant follow-up at 12 months (grade 2A; weak recommendation, high-quality evidence). (MacMahon, et al., 2017) Solitary noncalcified solid nodules measuring 6–8 mm in patients with low clinical risk are recommended to undergo initial follow-up at 6–12 months depending on size, morphology, and patient preference (grade 1C: strong recommendation, low- or very-low-quality evidence).

(MacMahon, et al., 2017) For solitary solid noncalcified nodules measuring 6–8 mm in patients at high risk, an initial follow-up examination is recommended at 6–12 months and again at 18–24 months (grade 1B: strong recommendation, moderate quality evidence). (MacMahon, et al., 2017) For solitary solid noncalcified nodules larger than 8 mm in diameter, consider 3-month follow-up, work-up with combined positron emission tomography (PET) and CT (PET/CT), tissue sampling, or a combination thereof; any one of these options may be appropriate depending on size, morphology, comorbidity, and other factors.

(grade 1A; strong recommendation, high-quality evidence). (MacMahon, et al., 2017) Recommendation 2: multiple solid noncalcified nodules. —For multiple solid noncalcified nodules smaller than 6 mm in diameter, no routine follow-up is recommended (grade 2B; weak recommendation, moderate-quality evidence). (MacMahon, et al., 2017) For multiple solid noncalcified nodules with at least one nodule 6 mm or larger in diameter, follow-up is recommended at approximately 3–6 months, followed by an optional second scan at 18–24 months that will depend on estimated risk.

(grade 1B; strong recommendation, moderate-quality evidence). (MacMahon, et al., 2017) Recommendation 3: solitary pure ground-glass nodules. —For pure ground-glass nodules smaller than 6 mm (i.e., 5 mm and smaller) in diameter, no routine follow-up is recommended (grade 1B; strong recommendation, moderate- quality evidence). (MacMahon, et al., 2017) For pure ground-glass nodules 6 mm or larger, follow-up scanning is recommended at 6–12 months and then every 2 years thereafter until 5 years (grade 1B; strong recommendation, moderate-quality evidence).

(MacMahon, et al., 2017) Recommendation 4: solitary part solid lung nodules. —For solitary part solid nodules smaller than 6 mm, no routine follow-up is recommended (grade 1C; strong recommendation, low- or very-low-quality evidence). (MacMahon, et al., 2017) For solitary part-solid nodules with a solid component 6 mm or larger, a short-term follow-up CT scan at 3–6 months should be considered to evaluate for persistence of the nodule.

For nodules with particularly suspicious morphology (i.e., lobulated margins or cystic components), a growing solid component, or a solid component larger than 8 mm, PET/CT, biopsy, or resection are recommended (grade 1B; strong recommendation, moderate quality evidence.) (MacMahon, et al., 2017) Recommendation 5: multiple subsolid lung nodules. —In patients with multiple subsolid nodules smaller than 6 mm, one must consider infectious causes.

If lesions remain persistent after an initial follow-up scan at 3–6 months, consider follow-up at approximately 2 and 4 years to confirm stability, depending on the clinical setting (grade 1C; strong recommendation, low- or very-low-quality evidence). (MacMahon, et al.

This measure contains one strata defined by a single submission criteria. The measure produces a single performance rate. Implementation Consideration: For the purposes of MIPS implementation, this procedure measure is submitted each time a procedure is performed during the performance period. Telehealth: NOT TELEHEALTH ELIGIBLE: This measure is not appropriate for nor applicable to the telehealth setting.

This measure is procedure based and therefore doesn’t allow for the denominator criteria to be conducted via telehealth. It would be appropriate to remove these patients from the denominator eligible patient population. Telehealth eligibility is at the measure level for inclusion within the denominator eligible patient population and based on the measure specification definitions which are independent of changes to coding and/or billing practices.

Measure Submission: The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this collection type for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. The coding provided to identify the measure criteria: Denominator or Numerator, may be an example of coding that could be used to identify patients that meet the intent of this clinical topic.

When implementing this measure, please refer to the ‘Reference Coding’ section to determine if other codes or code languages that meet the intent of the criteria may also be used within the medical record to identify and/or assess patients. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.