Metadata
Title | Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Level) FHIR
Version | 1.0.000
Short Name | CMS1056FHIR
GUID (Version Independent) | urn:uuid:e5321c7f-e853-42af-a65a-1957b15bab23
GUID (Version Specific) | urn:uuid:3f490338-faef-4c98-b422-95cd54c2c137
CMS Identifier | 1056FHIR
CMS Consensus Based Entity Identifier | 3662e
Effective Period | 2026-01-01 through 2026-12-31
Steward (Publisher) | Alara Imaging, Inc.
Developer | University of California San Francisco
Description | This measure provides a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality. It is expressed as a % of patients with CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality relative to evidence-based thresholds based on the clinical indication for the exam. All diagnostic CT exams of specified anatomic sites performed in inpatient, outpatient and ambulatory care settings are eligible. This measure is not telehealth eligible. This eCQM requires the use of additional software to access primary data elements stored within radiology electronic health records and translate them into data elements that can be ingested by this eCQM. Additional details are included in the Guidance field.
Copyright | The translation software was written and will be updated and maintained by Alara Imaging and will be accessible by creating a secure account through Alara’s website. Copyright (C) 2024 Alara Imaging, Inc. All Rights Reserved. This Measure and related data specifications are owned by Alara Imaging, Inc. Alara Imaging, Inc. is not responsible for any use of the Measure. Alara Imaging, Inc. makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and Alara Imaging, Inc. has no liability to anyone who relies on such measures or specifications. The Measure can be reproduced and distributed, without modification, for noncommercial purposes (e.g., use by healthcare providers in connection with their practices). 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 Alara Imaging, Inc. and are subject to a license at the discretion of Alara Imaging, Inc.
Disclaimer | The Measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications. Alara Imaging, Inc., the University of California San Francisco, and its members and users shall not be responsible for any use or accuracy of the Measure or any code contained within the Measure. THE MEASURE AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND. Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. Alara Imaging, Inc. disclaims all liability for use or accuracy of any third-party code contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2023 American Medical Association. LOINC(R) is copyright 2004-2023 Regenstrief Institute, Inc. SNOMED Clinical Terms(R) (SNOMED CT[R]) is copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2023 World Health Organization. All Rights Reserved. Due to technical limitations, registered trademarks are indicated by (R) or [R].
Rationale | Diagnostic imaging using CT occurs in more than a third of acute care hospitalizations in the U.S. (Vance, 2013) and greater than 90 million scans are performed annually in the U.S. (IMV, 2019). There is marked observed variation in the radiation doses used to perform these exams (Smith-Bindman, 2019). The inconsistency in how CT exams are performed represents a significant, unnecessary, and modifiable iatrogenic health risk, as there is extensive epidemiological and biological evidence that suggests exposure to radiation in the same range as that routinely delivered by CT increases a person's risk of developing cancer (Board of Radiation Effects, 2006; Grant, 2017; Hong, 2019; Sakata, 2019; Sadakane, 2019, references a and b; Bernier, 2019; Meulepas, 2019; Brenner, 2020; Berrington de Gonzalez, 2020; Sugiyama, 2020; Hauptmann, 2020; Huang, 2020; Abalo, 2021; Cao, 2022; Hauptmann, 2023). It is estimated that 2% (37,000) of the 1.8 million cancers diagnosed annually in the U.S. are caused by CT exams (Berrington de Gonzalez, 2009; NCI Cancer Statistics, 2020). The measure focuses on reducing radiation dose in CT, an intermediate outcome directly and proportionally related to cancer prevention. As radiation dose is known to be directly related and proportional to future cancer risk (Board of Radiation Effects, 2006; Berrington de Gonzalez, 2009), any reduction in radiation exposure would be expected to lead to a proportional reduction in cancers. Research suggests that when healthcare organizations and clinicians are provided with a summary of their CT radiation doses, their subsequent doses can be reduced without changing the usefulness of these tests (Smith-Bindman, 2020). On the basis of the current estimated number of CT scans performed annually in the U.S. (IMV, 2019), distribution in scan types and observed doses (Demb, 2017; Smith-Bindman, 2019), modeling of the cancer risk associated with CT at different ages of exposure (Berrington de Gonzalez, 2009), and costs of cancer care (Dieguez, 2017; Mariotto, 2011), an estimated 13,982 cancers could be prevented among Medicare beneficiaries annually, resulting in $1.86 billion to $5.21 billion annual cost savings. These cost calculations were supported by more recent data on cancer survivorship and costs, which yielded an estimated $3.04 billion dollars in annual costs savings to Medicare. (Mariotto, 2020; NCI Office of Cancer Survivorship, 2022).
Clinical Recommendation Statement | The measure aligns with numerous evidence- and consensus-based clinical guidelines asking radiologists to track, optimize, and lower CT radiation doses, guidelines that have been written by the American College of Radiology (Kanal, 2017), cardiovascular imaging societies (Hirshfeld, 2018, references a, b and c noted below), Image Gently Alliance, an initiative begun by the American College of Radiology, the Radiological Society of North America, American Society of Radiologic Technologists, the American Association of Physicists in Medicine, and the Society of Pediatric Radiology, which dozens of U.S. and international organizations have joined as recently as 2020 (Image Gently Alliance, 2022), and the US Food and Drug Administration (FDA, 2019). This measure has been strongly supported by a Technical Expert Panel (TEP) comprising a diverse group of clinicians, patient advocates, and leaders of medical specialty societies, payers, and healthcare safety and accrediting organizations, all of whom were engaged through every stage of measure conceptualization, development, and testing. In assessing the face validity of the measure, 100% of TEP members agreed radiation dose and global noise are relevant metrics of CT quality, that size is an appropriate method of risk adjustment, and that performance on this measure of radiation dose and image quality as specified is a representation of quality.
Citation | Berrington de Gonzalez A, Mahesh M, Kim KP, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med. 2009;169(22):2071-2077.
Citation | Board of Radiation Effects Research Division on Earth and Life Sciences National Research Council of the National Academies. Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2, Washington, D.C.: The National Academies Press; 2006.
Citation | Brenner DJ, Doll R, Goodhead DT, et al. Cancer risks attributable to low doses of ionizing radiation: assessing what we really know. Proc Natl Acad Sci U S A. 2003;100(24):13761-13766.
Citation | Demb J, Chu P, Nelson T, et al. Optimizing Radiation Doses for Computed Tomography Across Institutions: Dose Auditing and Best Practices. JAMA Intern Med. 2017;177(6):810-81.
Citation | Dieguez G, Ferro C, Pyenson B. Milliman Research Report: A Multi-Year Look at the Cost Burden of Cancer Care. April 11, 2017. https://www.milliman.com/en/insight/2017/a-multi-year-look-at-the-cost-burden-of-cancer-care
Citation | Halliburton SS, Abbara S, Chen MY, et al. SCCT guidelines on radiation dose and dose-optimization strategies in cardiovascular CT. J Cardiovasc Comput Tomogr. 2011;5(4):198-224.
Citation | Hong JY, Han K, Jung JH, Kim JS. Association of Exposure to Diagnostic Low-Dose Ionizing Radiation With Risk of Cancer Among Youths in South Korea. JAMA Netw Open. 2019;2(9):e1910584.
Citation | Hricak H, Brenner DJ, Adelstein SJ, et al. Managing Radiation Use in Medical Imaging: A Multifaceted Challenge. Radiology. 2010.
Citation | Image Wisely 2020. The American College of Radiology and the Radiological Society of North America formed the Joint Task Force on Adult Radiation Protection to address concerns about the surge of public exposure to ionizing radiation from medical imaging. The Joint Task Force collaborated with the American Association of Physicists in Medicine and the American Society of Radiologic Technologists to create the Image Wisely campaign with the objective of lowering the amount of radiation used in medically necessary imaging studies and eliminating unnecessary procedures. https://www.imagewisely.org/
Citation | IMV 2019 CT Market Outlook Report, https://imvinfo.com/ct-departments-seek-workflow-improvements-to-address-increased-ct-utilization/
Citation | Kanal KM, Butler PF, Sengupta D, Bhargavan-Chatfield M, Coombs LP, Morin RL. U.S. Diagnostic Reference Levels and Achievable Doses for 10 Adult CT Examinations. Radiology. 2017;284(1):120-133.
Citation | Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst. 2011 Jan 19;103(2):117-28. doi: 10.1093/jnci/djq495. Epub 2011 Jan 12. Erratum in: J Natl Cancer Inst. 2011 Apr 20;103(8):699. PMID: 21228314.
Citation | National Cancer Institute Cancer Statistics. https://www.cancer.gov/about-cancer/understanding/statistics accessed May 25, 2021
Citation | Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012;380(9840):499-505.
Citation | Pierce DA, Preston DL. Radiation-related cancer risks at low doses among atomic bomb survivors. Radiation research. 2000;154(2):178-186.
Citation | Preston DL, Ron E, Tokuoka S, et al. Solid cancer incidence in atomic bomb survivors: 1958-1998. Radiation research. 2007;168(1):1-64.
Citation | Shuryak I, Sachs RK, et al. Cancer risks after radiation exposure in middle age. J Natl Cancer Inst. 2010;102(21):1628-1636.
Citation | Smith-Bindman R, Lipson J, Marcus R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med. 2009;169(22):2078-2086.
Citation | Smith-Bindman R, Moghadassi M, Wilson N, et al. Radiation Doses in Consecutive CT Examinations from Five University of California Medical Centers. Radiology. 2015;277(1):134-141.
Citation | Smith-Bindman R, Wang Y, Chu P, et al. International variation in radiation dose for computed tomography examinations: prospective cohort study. BMJ. 2019;364:k4931.
Citation | Smith-Bindman R, Chu P, Wang Y, et al. Comparison of the Effectiveness of Single-Component and Multicomponent Interventions for Reducing Radiation Doses in Patients Undergoing Computed Tomography: A Randomized Clinical Trial. JAMA Intern Med. 2020 May 1;180(5):666-675.
Citation | Stecker MS, Balter S, Towbin RB, et al. Guidelines for patient radiation dose management. J Vasc Interv Radiol. 2009;20(7 Suppl):S263-273.
Citation | U.S. Food and Drug Administration. FDA White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging. 2019; https://www.fda.gov/radiation-emitting-products/initiative-reduce-unnecessary-radiation-exposure-medical-imaging/white-paper-initiative-reduce-unnecessary-radiation-exposure-medical-imaging.
Citation | Vance EA, Xie X, Henry A, Wernz C, Slonim AD. Computed tomography scan use variation: patient, hospital, and geographic factors. Am J Manag Care. 2013 Mar 1;19(3):e93-9. PMID: 23534948.
Citation | Writing Committee M, Hirshfeld JW, Jr., Ferrari VA, et al. 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging-Best Practices for Safety and Effectiveness, Part 2: Radiological Equipment Operation, Dose-Sparing Methodologies, Patient and Medical Personnel Protection. J Am Coll Cardiol. 2018.
Citation | Writing Committee M, Hirshfeld JW, Jr., Ferrari VA, et al. 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol. 2018.
Citation | Writing Committee M, Hirshfeld JW, Jr., Ferrari VA, et al. 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging-Best Practices for Safety and Effectiveness, Part 1: Radiation Physics and Radiation Biology. J Am Coll Cardiol. 2018.
Guidance (Usage) | This is an inverse measure; as such the higher the value the worse the performance. The level of aggregation for this eCQM is the clinician. Parallel eCQMs report CT exams performed in inpatient and outpatient hospital settings and is aggregated on the facility level. A single CT exam may be simultaneously measured in both the MIPS and one of the hospital reporting programs (inpatient or outpatient); however, a single exam cannot be measured in both the inpatient and outpatient hospital quality reporting programs. TRANSLATION SOFTWARE As a radiology measure, the measure derives standardized data elements from structured fields within both the electronic health record (EHR) and the radiology electronic clinical data systems, including the Radiology Information System (RIS) and the Picture Archiving and Communication System (PACS). Primary imaging data including Radiation Dose Structured Reports and image pixel data are stored in the PACS in Digital Imaging and Communications in Medicine (DICOM) format, a universally adopted standard for medical imaging information. Because of limitations in their specifications and format, eCQMs cannot currently access and consume elements from these radiology sources in their original DICOM formats. Thus, translation software was developed to transform primary data into a format that the eCQM can consume. This eCQM requires the use of additional software (translation software) to access the primary data elements that are required for measure computation and translate them into data elements that can be ingested by this eCQM. The purpose of this translation software is to access and link these primary data elements with minimal site burden, assess each CT exam for eligibility based on initial population criteria, and generate the three data elements mapped to a clinical terminology for eCQM consumption: CT Dose and Image Quality Category, Calculated CT Size-Adjusted Dose, and Calculated CT Global Noise. The free translation software necessary to use this eCQM is written and maintained by Alara Imaging, Inc. However, any software vendor capable of calculating and reporting this eCQM in accordance with the measure’s specifications, including combining radiology data with electronic health system data, and transforming radiology data into a format compatible with eCQM reporting, may report this measure on behalf of hospitals and clinicians. CODING The translation software will create three variables required for measure computation including the CT Dose and Image Quality Category (LOINC(R) Code 96914-7), the Calculated CT Global Noise (LOINC(R) Code 96912-1) and the Calculated CT Size-Adjusted Dose (LOINC(R) Code 96913-9). These variables are defined in the Definition field above. These transformed data elements can be stored in the EHR. MEASURE CALCULATION The measure will evaluate each included CT exam for a patient based on allowable thresholds that are specified by the CT Dose and Image Quality Category. An exam is considered out of range if either the Calculated CT Global Noise or the Calculated CT Size-Adjusted Dose is out of range for the CT Dose and Image Quality Category. Exams will be evaluated against their corresponding threshold, shown below with the following format: [Category shorthand (=CT Dose and Image Quality Category), threshold for the Calculated CT Global Noise in Hounsfield units, threshold for the Calculated CT Size-Adjusted Dose in dose length product]. [LA31752-1 (=Abdomen and Pelvis, Low Dose), 64, 598]; [LA31753-9 (=Abdomen and Pelvis, Routine Dose), 29, 644]; [LA31754-7 (=Abdomen and Pelvis, High Dose), 29, 1260]; [LA31755-4 (=Cardiac Low Dose), 55, 93]; [LA31756-2 (=Cardiac Routine Dose), 32, 576]; [LA31758-8 (=Chest Low Dose), 55, 377]; [LA31759-6 (=Chest Routine Dose), 49, 377]; [LA31761-2 (=Chest High Dose or Cardiac High Dose), 49, 1282]; [LA31762-0 (=Head Low Dose), 115, 582]; [LA31763-8 (=Head Routine Dose), 115, 1025]; [LA31764-6 (=Head High Dose), 115, 1832]; [LA31765-3 (=Upper or Lower Extremity), 73, 320]; [LA31766-1 (=Neck or Cervical Spine), 25, 1260]; [LA31767-9 (=Thoracic or Lumbar Spine), 25, 1260]; [LA31768-7 (=Combined Chest, Abdomen and Pelvis), 29, 1637]; [LA31851-1 (=Combined Thoracic and Lumbar Spine), 25, 2520]; [LA31769-5 (=Combined Head and Neck, Routine Dose), 25, 2285]; [LA31770-3 (=Combined Head and Neck, High Dose), 25, 3092] EXCLUSIONS CT scans with missing patient age or missing CT Dose and Image Quality Category (LOINC(R) 96914-7) are excluded from the initial population. CT scans with a missing Calculated Global Noise value or a missing Calculated CT Size-Adjusted Dose value are not included in the denominator. Patients that have one or more CT scans assigned a CT Dose and Image Quality Category (LOINC(R) 96914-7) value using the LOINC(R) answer list (LL5824-9) of full body (LA31771-1) during the measurement period are excluded from the denominator. These exams are included in the initial population because they have a non-missing CT Dose and Image Quality Category but are then removed as a Denominator Exclusion in the eCQM because the value is full body, which reflects CT exams that cannot be categorized by anatomical area or by clinical indication, either because they are simultaneous exams of multiple body regions outside of four commonly encountered multiple region groupings, or because there is insufficient data for their classification based on the given diagnosis and procedure codes. This eCQM is a patient-based measure and should report the percentage of patients that had an eligible CT scan performed during the measurement period that had either a size adjusted dose or noise level out of range. Telehealth encounters are not eligible for this measure because the measure does not contain telehealth-eligible encounter codes. This FHIR-based measure has been derived from the QDM-based measure: CMS1056v2. Please refer to the HL7 QI-Core Implementation Guide (https://hl7.org/fhir/us/qicore/STU6/) for more information on QI-Core and mapping recommendations from QDM to QI-Core STU 6 (https://hl7.org/fhir/us/qicore/STU6/qdm-to-qicore.html).
Measure Group (Rate) (ID: Group_1)
Basis | boolean
Scoring | [http://terminology.hl7.org/CodeSystem/measure-scoring#proportion: 'Proportion']
Type | [http://terminology.hl7.org/CodeSystem/measure-type#intermediate-outcome: 'Intermediate Outcome']
Rate Aggregation | None
Improvement Notation | [http://terminology.hl7.org/CodeSystem/measure-improvement-notation#decrease: 'Decreased score indicates improvement']
Initial Population | ID: InitialPopulation_1 Description: Patients aged 18 years and older at the start of the measurement period that have an eligible CT scan with Dose and Image Quality Category performed during the measurement period Logic Definition: Initial Population
Denominator | ID: Denominator_1 Description: Equals Initial population where an eligible CT scan has a Calculated Global Noise value and a Calculated CT Size-Adjusted Dose value Logic Definition: Denominator
Denominator Exclusion | ID: DenominatorExclusion_1 Description: Patients with one or more eligible CT scans that has a CT Dose and Image Quality Category = full body Logic Definition: Denominator Exclusion
Numerator | ID: Numerator_1 Description: Patients with one or more eligible CT scans with calculated CT Size-Adjusted Dose greater than or equal to a threshold specific to the CT Dose and Image Quality Category, or Calculated CT Global Noise value greater than or equal to a threshold specific to the CT Dose and Image Quality Category Logic Definition: Numerator
Supplemental Data Guidance | For every patient evaluated by this measure also identify payer, race, ethnicity and sex; SDE Ethnicity SDE Payer SDE Race SDE Sex
Supplemental Data Elements
Supplemental Data Element | ID: sde-ethnicity Usage Code: [http://terminology.hl7.org/CodeSystem/measure-data-usage#supplemental-data] Description: SDE Ethnicity Logic Definition: SDE Ethnicity
Supplemental Data Element | ID: sde-payer Usage Code: [http://terminology.hl7.org/CodeSystem/measure-data-usage#supplemental-data] Description: SDE Payer Logic Definition: SDE Payer
Supplemental Data Element | ID: sde-race Usage Code: [http://terminology.hl7.org/CodeSystem/measure-data-usage#supplemental-data] Description: SDE Race Logic Definition: SDE Race
Supplemental Data Element | ID: sde-sex Usage Code: [http://terminology.hl7.org/CodeSystem/measure-data-usage#supplemental-data] Description: SDE Sex Logic Definition: SDE Sex
Measure Logic
Primary Library | https://madie.cms.gov/Library/CMS1056FHIRCTClinical
Contents | Population Criteria Logic Definitions Terminology Dependencies Data Requirements
Population Criteria
Measure Group (Rate) (ID: Group_1)
Initial Population
    define "Initial Population":
      exists ( "Patients with Qualifying CTScan" )
Denominator
    define "Denominator":
      exists ( "Patients with Qualifying CTScan with Values" )
Denominator Exclusion
    define "Denominator Exclusion":
      exists ( "Patients with Qualifying CTScan with Values" CTScanWithValues
          where ( CTScanWithValues.value as Concept ).codes contains "Full Body"
      )
Numerator
    define "Numerator":
      exists ( "Patients with Qualifying CTScan with Values" CTScanWithValues
          where CTScanWithValues.ctScanQualifies ( )
      )
Logic Definitions
Logic Definition | Library Name: SupplementalDataElements
    define "SDE Sex":
      case
        when Patient.sex = '248153007' then "Male (finding)"
        when Patient.sex = '248152002' then "Female (finding)"
        else null
      end
Logic Definition | Library Name: SupplementalDataElements
    define "SDE Payer":
      [Coverage: type in "Payer Type"] Payer
        return {
          code: Payer.type,
          period: Payer.period
        }
Logic Definition | Library Name: SupplementalDataElements
    define "SDE Ethnicity":
      Patient.ethnicity E
        return Tuple {
          codes: { E.ombCategory } union E.detailed,
          display: E.text
        }
Logic Definition | Library Name: SupplementalDataElements
    define "SDE Race":
      Patient.race R
        return Tuple {
          codes: R.ombCategory union R.detailed,
          display: R.text
        }
Logic Definition | Library Name: CMS1056FHIRCTClinical
    define "SDE Sex":
      SDE."SDE Sex"
Logic Definition | Library Name: CMS1056FHIRCTClinical
    define "Patients with Qualifying CTScan":
      [ObservationClinicalResult: "CT dose and image quality category"] CTScanResult
        where CTScanResult.status in { 'final', 'amended', 'corrected' }
          and CTScanResult.effective.toInterval ( ) ends during day of "Measurement Period"
          and ( AgeInYearsAt(date from start of "Measurement Period") >= 18 )
Logic Definition | Library Name: CMS1056FHIRCTClinical
    define "Patients with Qualifying CTScan with Values":
      "Patients with Qualifying CTScan" CTScan
        where CTScan.globalNoiseValue ( ) is not null
          and CTScan.sizeAdjustedValue ( ) is not null
          and CTScan.value is not null
Logic Definition | Library Name: CMS1056FHIRCTClinical
    define "Numerator":
      exists ( "Patients with Qualifying CTScan with Values" CTScanWithValues
          where CTScanWithValues.ctScanQualifies ( )
      )
Logic Definition | Library Name: CMS1056FHIRCTClinical
    define "Denominator":
      exists ( "Patients with Qualifying CTScan with Values" )
Logic Definition | Library Name: CMS1056FHIRCTClinical
    define "SDE Payer":
      SDE."SDE Payer"
Logic Definition | Library Name: CMS1056FHIRCTClinical
    define "Initial Population":
      exists ( "Patients with Qualifying CTScan" )
Logic Definition | Library Name: CMS1056FHIRCTClinical
    define "SDE Ethnicity":
      SDE."SDE Ethnicity"
Logic Definition | Library Name: CMS1056FHIRCTClinical
    define "Denominator Exclusion":
      exists ( "Patients with Qualifying CTScan with Values" CTScanWithValues
          where ( CTScanWithValues.value as Concept ).codes contains "Full Body"
      )
Logic Definition | Library Name: CMS1056FHIRCTClinical
    define "SDE Race":
      SDE."SDE Race"
Logic Definition | Library Name: AlaraCommonFunctions
    /* Note since the units has a special character in it this must be escaped in the CQL */
    define fluent function "globalNoiseValue"(Result ObservationClinicalResult ):
      singleton from ( Result.component C
          where Result.status in { 'final', 'amended', 'corrected' }
            and C.code ~ "Calculated CT global noise"
            and ( C.value as Quantity ).unit = '[hnsf\'U]'
          return (C.value as Quantity).value
      )
Logic Definition | Library Name: AlaraCommonFunctions
    define fluent function "sizeAdjustedValue"(Result ObservationClinicalResult ):
      singleton from ( Result.component C
          where Result.status in { 'final', 'amended', 'corrected' }
            and C.code ~ "Calculated CT size-adjusted dose"
            and ( C.value as Quantity ).unit = 'mGy.cm'
          return (C.value as Quantity).value
      )
Logic Definition | Library Name: AlaraCommonFunctions
    define fluent function "ctScanQualifies"(Result ObservationClinicalResult ):
      Result.qualifies("Abdomen and Pelvis Low Dose", 64, 598)
        or Result.qualifies("Abdomen and Pelvis Routine Dose", 29, 644)
        or Result.qualifies("Abdomen and Pelvis High Dose", 29, 1260)
        or Result.qualifies("Cardiac Low Dose", 55, 93)
        or Result.qualifies("Cardiac Routine Dose", 32, 576)
        or Result.qualifies("Chest Low Dose", 55, 377)
        or Result.qualifies("Chest Routine Dose", 49, 377)
        or Result.qualifies("Cardiac High Dose or Chest High Dose", 49, 1282)
        or Result.qualifies("Head Low Dose", 115, 582)
        or Result.qualifies("Head Routine Dose", 115, 1025)
        or Result.qualifies("Head High Dose", 115, 1832)
        or Result.qualifies("Extremity", 73, 320)
        or Result.qualifies("Neck or Cervical Spine", 25, 1260)
        or Result.qualifies("Thoracic or Lumbar Spine", 25, 1260)
        or Result.qualifies("Simultaneous Chest and Abdomen and Pelvis", 29, 1637)
        or Result.qualifies("Simultaneous Thoracic and Lumbar Spine", 25, 2520)
        or Result.qualifies("Simultaneous Head and Neck Routine Dose", 25, 2285)
        or Result.qualifies("Simultaneous Head and Neck High Dose", 25, 3092)
Logic Definition | Library Name: AlaraCommonFunctions
    define fluent function "qualifies"(Result ObservationClinicalResult, code System.Code, noiseThreshold Decimal, sizeDoseThreshold Decimal ):
      (Result.value as Concept) ~ code
        and ( Result.globalNoiseValue() >= noiseThreshold
            or Result.sizeAdjustedValue() >= sizeDoseThreshold
        )
Logic Definition | Library Name: FHIRHelpers
    define function ToString(value uri): value.value
Logic Definition | Library Name: FHIRHelpers
    /*
    @description: Converts the given [Period](https://hl7.org/fhir/datatypes.html#Period)
    value to a CQL DateTime Interval
    @comment: If the start value of the given period is unspecified, the starting
    boundary of the resulting interval will be open (meaning the start of the interval
    is unknown, as opposed to interpreted as the beginning of time).
    */
    define function ToInterval(period FHIR.Period):
        if period is null then
            null
        else
            if period."start" is null then
                Interval(period."start".value, period."end".value]
            else
                Interval[period."start".value, period."end".value]
Logic Definition | Library Name: FHIRHelpers
    /*
    @description: Converts the given FHIR [Coding](https://hl7.org/fhir/datatypes.html#Coding) value to a CQL Code.
    */
    define function ToCode(coding FHIR.Coding):
        if coding is null then
            null
        else
            System.Code {
              code: coding.code.value,
              system: coding.system.value,
              version: coding.version.value,
              display: coding.display.value
            }
Terminology
Code System | Description: Code system SNOMEDCT Resource: http://snomed.info/sct Canonical URL: `http://snomed.info/sct`
Code System | Description: Code system LOINC Resource: http://loinc.org Canonical URL: `http://loinc.org`
Value Set | Description: Value set Payer Type Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591`
Direct Reference Code | Display: Male (finding) Code: 248153007 System: `http://snomed.info/sct`
Direct Reference Code | Display: Female (finding) Code: 248152002 System: `http://snomed.info/sct`
Direct Reference Code | Display: CT dose and image quality category Code: 96914-7 System: `http://loinc.org`
Direct Reference Code | Display: Calculated CT global noise Code: 96912-1 System: `http://loinc.org`
Direct Reference Code | Display: Calculated CT size-adjusted dose Code: 96913-9 System: `http://loinc.org`
Direct Reference Code | Display: Abdomen and Pelvis Low Dose Code: LA31752-1 System: `http://loinc.org`
Direct Reference Code | Display: Abdomen and Pelvis Routine Dose Code: LA31753-9 System: `http://loinc.org`
Direct Reference Code | Display: Abdomen and Pelvis High Dose Code: LA31754-7 System: `http://loinc.org`
Direct Reference Code | Display: Cardiac Low Dose Code: LA31755-4 System: `http://loinc.org`
Direct Reference Code | Display: Cardiac Routine Dose Code: LA31756-2 System: `http://loinc.org`
Direct Reference Code | Display: Chest Low Dose Code: LA31758-8 System: `http://loinc.org`
Direct Reference Code | Display: Chest Routine Dose Code: LA31759-6 System: `http://loinc.org`
Direct Reference Code | Display: Cardiac High Dose or Chest High Dose Code: LA31761-2 System: `http://loinc.org`
Direct Reference Code | Display: Head Low Dose Code: LA31762-0 System: `http://loinc.org`
Direct Reference Code | Display: Head Routine Dose Code: LA31763-8 System: `http://loinc.org`
Direct Reference Code | Display: Head High Dose Code: LA31764-6 System: `http://loinc.org`
Direct Reference Code | Display: Extremity Code: LA31765-3 System: `http://loinc.org`
Direct Reference Code | Display: Neck or Cervical Spine Code: LA31766-1 System: `http://loinc.org`
Direct Reference Code | Display: Thoracic or Lumbar Spine Code: LA31767-9 System: `http://loinc.org`
Direct Reference Code | Display: Simultaneous Chest and Abdomen and Pelvis Code: LA31768-7 System: `http://loinc.org`
Direct Reference Code | Display: Simultaneous Thoracic and Lumbar Spine Code: LA31851-1 System: `http://loinc.org`
Direct Reference Code | Display: Simultaneous Head and Neck Routine Dose Code: LA31769-5 System: `http://loinc.org`
Direct Reference Code | Display: Simultaneous Head and Neck High Dose Code: LA31770-3 System: `http://loinc.org`
Direct Reference Code | Display: Full Body Code: LA31771-1 System: `http://loinc.org`
Dependencies
Dependency | Description: QICore model information Resource: http://hl7.org/fhir/Library/QICore-ModelInfo Canonical URL: `http://hl7.org/fhir/Library/QICore-ModelInfo`
Dependency | Description: Library SDE Resource: https://madie.cms.gov/Library/SupplementalDataElements|5.1.000 Canonical URL: `https://madie.cms.gov/Library/SupplementalDataElements|5.1.000`
Dependency | Description: Library FHIRHelpers Resource: https://madie.cms.gov/Library/FHIRHelpers|4.4.000 Canonical URL: `https://madie.cms.gov/Library/FHIRHelpers|4.4.000`
Dependency | Description: Library QICoreCommon Resource: https://madie.cms.gov/Library/QICoreCommon|4.0.000 Canonical URL: `https://madie.cms.gov/Library/QICoreCommon|4.0.000`
Dependency | Description: Library AlaraCommon Resource: https://madie.cms.gov/Library/AlaraCommonFunctions|1.10.000 Canonical URL: `https://madie.cms.gov/Library/AlaraCommonFunctions|1.10.000`
Data Requirements
Data Requirement | Type: Patient Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient Must Support Elements: extension, url
Data Requirement | Type: Observation Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation-clinical-result Must Support Elements: status, code, value, value.unit, value.value, status.value
Data Requirement | Type: Observation Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation-clinical-result Must Support Elements: code, status, status.value, effective, value, value.unit, value.value, value.codes Code Filter(s): Path: code Code(s): http://loinc.org#96914-7: 'CT dose and image quality category'
Data Requirement | Type: Coverage Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-coverage Must Support Elements: type, period Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
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