Posted on Leave a comment

Using the DIR to Meet CMS’s Quality Reporting Requirements in Radiology: Important Information You Need To Know

In 2018 radiologists may report three Dose Index Registry (DIR) Measures to meet a portion of their MACRA/MIPS Quality Payment Program (QPP) requirements.  These submissions will contribute to an overall Quality Score.  In years past merely participating in the DIR qualified as meeting the DIR-eligible QPP Measures.  However, in 2018 merely participating in the DIR is not enough; instead, radiologists will be evaluated based on how their submitted doses compare to others in the DIR.  The aim of this article is to discuss the three DIR Measures which radiologists may report, the implications of the doses they submit to the DIR, and what steps radiology groups need to take now to ensure success.


In 2018 CMS is accepting DIR data to qualify for 3 High Priority non-MIPS Measures:

  1. ACRad 31: Percent of CT Abdomen w/ contrast exams whose Total DLP per Exam is at or below the Diagnostic Reference Level as reported by the DIR for all facilities;
  2. ACRad 32: Percent of Chest wo/ contrast exam whose Total DLP per Exam is at or below Diagnostic Reference Level as reported by the DIR for all facilities; and,
  3. ACRad 33: Percent of CT Head/Brain wo/ contrast exams whose Total DLP per Exam is at or below Diagnostic Reference Level as reported by the DIR for all facilities.

ACRad 2018 Measures

Note:  The Diagnostic Reference Levels (DRLs) are defined as the 75th Percentile; Achievable Doses (ADs) are defined as the Median reported dose for All DIR Sites.

Measure Credit & Score Discussion

To qualify for the Measure the reported Total DLP per Exam must be at or below the DRLs as reported by all DIR Sites.  If the Total DLP per Exam submitted is above the DRLs the radiologist will not meet Measure.  It is important to understand that all QPP calculations for DIR-related Measures are performed at the TIN level, and not by individual radiologist.

If the Total DLP per Exam submitted by the radiology group is below the DRLs the group radiologists will receive credit for the Measure.  The quality score awarded will be determined by comparing the group’s submitted doses to the doses submitted by other qualifying submitters.  In short, the lower the submitted doses on a comparative basis the higher the quality score awarded.

Here is an example.  As seen in Table 2 below, this fictitious group’s Median Total DLP per Exam for CT Abdomen w/ contrast was 1,093, which is above the 75th Percentile DRLs Dose for All DIR Sites (1061).  Therefore, none of the group’s radiologists would qualify for ACRad31 because the group’s Median doses were above the DRLs.

The fictitious group’s Median Total DLP per Exam for CT Chest wo Contrast (509) is below the 75th Percentile DRLs Dose for All DIR Sites (521).  This means the group’s radiologists would qualify for ACRad 32 Measure.  However, it is important to note that in this case, the Median reported dose is only marginally lower than the DRLs.  This means that, while qualifying for the Measure, the group is likely to be awarded minimal quality points.

Lastly, the fictitious group’s Median Total DLP per Exam for CT Head/Brain wo contrast (694) is below the 75th Percentile DRLs Dose for All DIR Sites (1066), which qualifies them ACRad33 Measure.  Additionally, their 694 Median dose is also well below the ADs reported by All DIR sites (872).  This means the group would likely receive a higher quality score since their doses are lower than most others submitting data.

Table 2 2018 QPP Measure Article

Challenge:  Who is monitoring the DIR on radiologists’ behalf? 

For many hospital-based practices, a facility technologist usually has the responsibility to map the studies to the DIR.  This has interesting implications for the radiologist.

While not complicated, exam mapping is nuanced, and therefore, the person performing it should have a working understanding RadLex Playbook Identifiers (RPID), the exam name mapping nomenclature, and how to perform the exam name mapping crosswalk to the Dose Index Registry.  Without adequate understanding of how RPIDS fit into the DIR it is easy for the person mapping studies to innocently mis-map studies, which can and will lead to undesirable outcomes for radiologists’ QPP reporting, while having no noticeable impact or consequences at the facility level.

Additionally, even if the exam name mapping is correct, it is possible for the dose reported to the DIR to be inappropriately inflated.  This can occur at the time of the exam if the technologist selects an incorrect protocol or misapplies the selection.  Here are two real-world examples:

Example 1 – Incorrect Mapping of Exams:  It is not uncommon for the person mapping exam names to map both single and multi-phase Abdomen/Pelvis studies w/ contrast RPID145 – CT Abdomen/Pelvis w/ contrast.  Doses for multi-phase studies are often double or more that of single-phase studies.  If that is occurring at the reporting group’s facility the doses reported QPP purposes will be inflated leading to lower quality scores and, if taken to an extreme, could lead to failure to qualify for the Measure.

Example 2 – Misapplication of a scanner protocol that results in additional series being performed under the protocol:  Don’t be misled by use of the word “protocol.”  For example, if a referring physician orders a CT Brain without and with contrast, it is possible for the technologist to select the CT Brain without contrast scanner protocol, then just perform both the without and then the with series with that protocol.  This would cause the DIR to map the study to RPID22, CT Brain wo contrast, but with double the dose.  Please note that in this example the RIS/PACS , reporting, and billing processes would correctly reflect the without and with study performed; only the DIR would be mis-mapped.

Strategy for radiology groups to maximize the DIR for QPP purposes

First and foremost, radiology groups need to take proactive steps by reviewing their facility’s most recent DIR report with special attention paid to exams related to QPP Measures ACRad 31, 32, or 33:  CT Abd/Pelvis w/ contrast, CT Chest wo contrast, and CT Brain wo contrast studies.  This includes reviewing the most recent set of Aggregate Reports to see if they are above or close to the DRLs and a detailed review of the Exam Name Mappings to identify any obviously mis-mapped studies.

If the Aggregate Results show the group’s Total DLP per Exam is at or near the Median (the ADL) for All DIR Sites, then they are likely well-positioned for submitting data to CMS.  In this case, the group, in my opinion, should perform an Exam Name Mapping Review just to eliminate the possibility of having obviously high dose studies mis-mapped to these studies.

However, if the Aggregate Results show the Total DLP per Exam submitted by the facility is near or above the 75th Percentile for All DIR Sites (DRLs) the group needs to take immediate action to determine why their doses are higher than many others reporting and explore opportunities to correct them.  In many cases, correcting them can be as simple as remapping incorrectly mapped studies e.g., remapping multi-phase from the single-phase RPID to the more appropriate multi-phase RPID.  In this case I also suggest the group undertake a more detailed, exam by exam review of the dose distribution during the review period.

Of course, high doses could also be caused by the scanner protocol scan parameters settings for the study.  Groups may also want to perform an in-depth review of the scan parameters for the QPP-related studies.  This would be worthwhile regardless of the current Aggregate Report levels to ensure doses are as low as possible.  The confounding factor here is that most facilities have multiple scanner protocols that need to be reviewed.  Multiple scanner protocols are relatively easy to identify by combining two DIR exports then using Excel VLOOKUP and Pivot Tables functions to combine and display the results.  Unfortunately for radiologists, staff typically involved with the DIR lack the Excel skills to perform this analysis.


In 2018 CMS is determining QPP success and awarding Quality points for DIR Measures ACRad31, 32, and/or 33 based on how the group’s reported DLP levels compare to others in the DIR. It is important for radiologists to review their DIR reports and take proactive steps to position themselves to maximize their opportunity in the QPP quality program.  Radiologists planning to use the QPP DIR Measures should review the most recent Aggregate Reports and the facility’s Exam Name Mappings for their QPP-related exams.

If the review identifies high DLP levels due to exam name mapping errors changes made today will correct previously submitted scan data for QPP purposes for the entire reporting year.  If high DLP levels are due to scanning parameters, changing parameters will lower doses from that point in time forward.  In both cases, it is important to take steps to review the current state soon for the 2018 reporting cycle.

—Dose Registry Support Services—

Dose Registry Support Services is able to provide the reviews described above, including the recommended initial Aggregate Report and Exam Name Mapping Review.  We can also provide more in-depth review and analysis specifically tailored to your needs, as well as a provide a framework and support for scan parameter review.

Our Basic Review service consists of a review of a single Master Account level Aggregate Report – Master Facility Excel Report (Adult) and Exam Name Mapping Export, and includes a review of:

  • the Total DLP per Exam doses Master level (overall) and for each site contained in the Master account for the QPP Measured studies; and,
  • the Exam Name Mapping review attempts to identify clearly mis mapped studies based on the protocol name submitted to the DIR.

Upon completion we will provide you with a written report of our findings and recommendations.  The total cost for a Basic Review is $175.000 per Master Account.

Click here to contact Dose Registry Support Services.


Michael Bohl

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.