Development of an Electronic Clinical Quality Measure for Excessive Radiation Dose or Inadequate Image Quality in Diagnostic CT in Adults.
Nov 3, 2026DOI: 10.1016/j.jacr.2026.09.021Journal ArticleJACR
Written by: Rebecca Smith-BindmanAndrew B BindmanMarc D KohliCarly StewartTimothy P SzczykutowiczRonald M KlinePatrick S Romano
The Excessive Radiation Dose or Inadequate Image Quality for Diagnostic CT in Adults (ExRad) measure is the first automated radiology outcome measure adopted by CMS. We describe its development, specification, calculation, and adoption. Beginning in 2018, the measure was developed under a CMS cooperative agreement following the Measures Management System Blueprint, with oversight from a multidisciplinary Technical Expert Panel. ExRad evaluates each adult diagnostic CT examination in three steps. First, the examination is assigned to 1 of 19 CT categories defined by anatomic region and clinical indication using International Classification of Diseases, 10th Revision, Clinical Modification and Current Procedural Terminology codes. Second, size-adjusted radiation dose and image noise are computed from the DICOM dose report and pixel data; because clinical and radiology data reside in separate systems, translation software inside the hospital firewall performs the linkage and calculations automatically. Third, dose and noise are compared with category-specific thresholds derived from a reader study in which 125 radiologists rated the image quality of 734 CT examinations. An examination is out of range if either value exceeds its threshold, and the measure score is the percentage of eligible examinations that are out of range. Testing across 32 facilities in eight health systems confirmed the availability, accuracy, validity, and reproducibility of all data elements, and the National Quality Forum endorsed the measure in 2021. CMS adopted ExRad in 2023 into hospital inpatient, hospital outpatient, and clinician quality reporting programs, with voluntary reporting beginning in 2025. It is the sole outcome measure in the Diagnostic Radiology MIPS (Merit-Based Incentive Payment System) Value Pathway.
