AAO13: Bell’s Palsy: Inappropriate Use of Magnetic Resonance Imaging or Computed Tomography Scan+

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High Priority Status: Yes / Appropriate Use

CBE Number: N/A

Measure Description:

Percentage of patients aged 16 years and older with a new onset diagnosis of Bell’s palsy who had a magnetic resonance imaging (MRI), or a computed tomography (CT) scan of the internal auditory canal, head, neck, or brain ordered within 3 months after diagnosis.

Instructions:

This measure is to be submitted a minimum of once per performance period for patients with a new onset of Bell’s Palsy during the performance period. This measure may be submitted by clinicians based on the measure-specific denominator coding.

Denominator:

All patients aged 16 years and older with a new onset diagnosis of Bell’s palsy.

Denominator Note:

To meet the denominator criteria, a patient must have a visit with a documented diagnosis of new onset Bell’s Palsy (G51.0). Due to the wide variation in the use of ICD-10 code, G51.0, the code description will be evaluated to confirm Bell’s Palsy.

Denominator Exclusions:

None

Denominator Criteria:

Patient aged 16 years and older

AND

Diagnosis: Bell’s Palsy (new onset)

AND

Patient Visit: Encounter Visit

For a list of codes that qualify as denominator eligible visits, reference Addendum attached.

Numerator:

Patients who had an MRI or CT scan of the internal auditory canal, head, neck, or brain ordered within 3 months after diagnosis.

Numerator Note:

To meet the intent of the measure, the patient with a diagnosis of Bell’s Palsy should not receive routine diagnostic imaging within the expected 3-month recovery time frame unless a denominator exception is met signifying that a patient has features atypical of Bell’s palsy.

INVERSE MEASURE – A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

Denominator Exceptions:

Medical reason(s) for ordering an MRI or CT scan of the internal auditory canal, head, neck, or brain for the

primary diagnosis of Bell’s palsy including:

• Patients with a diagnosis of Bell’s palsy more than 3 months prior to the date of the referral or performance of imaging with no signs of recovery.

• Patients with recurrent diagnosis of Bell’s
• Patients with paralysis limited to a specific branch, or branches, of the facial
• Patients with paralysis associated with other cranial nerve abnormalities, including olfactory nerve, glossopharyngeal nerve, vagus nerve, and hypoglossal nerve.
• Patients with other diagnosed neurological abnormalities, including simultaneous sudden hearing loss, tinnitus, and/or dizziness; stroke; tumor; seizures; extremity weakness; and/or extremity

Measure Classifications

• Submission Pathway: Traditional MIPS Measure Type: Process
• High Priority Type: Appropriate Use
• Meaningful Measures Area: Appropriate Use of Healthcare Care Setting(s): Ambulatory Care: Clinician Office/Clinic Includes Telehealth: Yes
• Number of Performance Rates: 1 Inverse measure: Yes Continuous measure: No Proportional measure: Yes Ratio measure: No
• Risk Adjusted measure: No

Clinical Recommendation Statement:

Clinicians should not routinely perform diagnostic imaging for patients with new-onset Bell’s palsy. Expanding on the initial recommendations, recent evidence and practice patterns further support the approach of withholding advanced imaging during the first weeks of new-onset Bell’s palsy in the absence of atypical features.

Observational data indicate that the majority of patients with classic presentations recover spontaneously, with more than two-thirds achieving complete recovery without the need for imaging or laboratory workup. Imaging is most often reserved for cases with atypical presentations, such as progressive symptoms, recurrent episodes, or additional neurologic deficits, or when there is incomplete recovery after several weeks to months. MRI findings in acute Bell’s palsy (within 7 days) may show facial nerve enhancement, but this does not alter management in typical cases and is not required for diagnosis.

Therefore, the consensus in the medical literature is to withhold advanced imaging for at least the first 3 months unless atypical features or lack of improvement prompt further evaluation. Advanced imaging should be obtained sooner than 3 months in patients with new onset of Bell’s palsy if there are features atypical for Bell’s palsy, such as recurrent paralysis on the same side, paralysis limited to isolated branches of the facial nerve, involvement of other cranial nerves, or a suggestive history (e.g., trauma or tumor).

Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guideline: Bell’s palsy. Otolaryngology Head Neck Surg. 2013;149(3 Suppl):S1-S27. doi:10.1177/0194599813505967

Rationale:

A large portion of patients with Bell’s Palsy will undergo nonindicated diagnostic testing and treatments prior to referral to a specialist. The routine use of diagnostic imaging is not recommended at the time of initial presentation of these patients. MRI and CT scans have some risks as well as considerable cost. Accordingly, the American College of Radiology (ACR) advises against imaging unless there is a clear medical benefit outweighing any associated risk.

The rationale for this recommendation is that routine imaging does not alter management, may lead to unnecessary further testing due to incidental findings, and exposes patients to unnecessary cost and potential risks (e.g., radiation, contrast reactions). Imaging is reserved for cases where the clinical course is not typical for Bell’s palsy or when recovery is not observed within the expected timeframe.

American College of Radiology. ACR statement on recent studies regarding CT scans and increased cancer risk.http://gm.acr.org/MainMenuCategories/media_room/FeaturedCategories/PressReleases/StatementonRece ntStudiesRegardingCTScans.aspx. Accessed 8.24.2017.

Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guideline: Bell’s palsy. Otolaryngology Head Neck Surg. 2013;149(3 Suppl):S1-S27. doi:10.1177/0194599813505967

Supporting Clinical Practice Guideline (CPG):

For more details, reference the Clinical Practice Guideline: Bell’s Palsy (2013)

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The measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications. The measure and specifications are provided “as is” without warranty of any kind. Neither the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF), nor its members shall be responsible for any use of the measure. The AAO-HNSF and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specification.

Addendum