The New CMS Measure of Excessive Radiation Dose or Inadequate Image Quality in CT: Issues and Ambiguities—Perspectives From an AAPM-Commissioned Panel

CMS has adopted a new CT quality measure seeking to discourage excessive radiation dose while preserving image quality. The measure score is expressed as the percentage of qualifying studies that exceed predetermined thresholds, indicating inadequate image quality (based on image noise) or excessive radiation dose. The measure has been incorporated into the major CMS quality-based payment programs, impacting hospitals and clinician payments; measure reporting began in January 2025. After measure development, practitioners identified a spectrum of concerns and impediments, prompting the American Association of Physicists in Medicine to convene a multidisciplinary expert panel to provide further guidance. The panel identified 20 issues and ambiguities in the measure specifications, stemming from metrology concerns, unconventional terminology, and inconsistencies with practice standards or norms; these issues relate to themes of applicability, categories and metrics, informatics, performance expectations, and meta considerations. In this article, the panel presents these issues and ambiguities with associated recommendations to promote the measure's intentions. These recommendations include greater data access (e.g., to the measure's source data and to reporting elements for audit support) and a more holistic treatment of image quality. The panel ultimately urges a shift toward open-source, open-access, consensus-based, and community-owned strategies to ensure CT quality and safety.