2023 # 066 Appropriate Testing for Pharyngitis

CMS Measure ID: #66

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: No

High Priority: Yes

NQS Domain: Efficiency and Cost Reduction

Measure Age: > 2 years

Instructions

This measure is to be submitted once for each occurrence of pharyngitis during the performance period. Claims data will be analyzed to determine unique occurrences. This measure is intended to reflect the quality of services provided for the primary management of patients with pharyngitis who were ordered an antibiotic. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. 

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

Measure Submission Type:

The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. 

Description

The percentage of episodes for patients 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic order and a group A streptococcus (strep) test in the seven-day period from three days prior to the episode date through three days after the episode date

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: Yes
Capped at 7: No

Decile 0: 0 – 26.08
Decile 1: 26.09 – 76.91
Minimum: 76.92 – 86.88
Decile 3: 86.89 – 91.99
Decile 4: 92 – 95.44
Decile 5: 95.45 – 97.63
Decile 6: 97.64 – 98.89
Decile 7: 98.9 – 99.99
Decile 10: 100 – 100

eCQM

Topped out: No
Capped at 7: No

Decile 0: 0 – 0.53
Decile 1: 0.54 – 7.4
Minimum: 7.41 – 21.99
Decile 3: 22 – 36.79
Decile 4: 36.8 – 52.42
Decile 5: 52.43 – 63.81
Decile 6: 63.82 – 72.72
Decile 7: 72.73 – 79.99
Decile 8: 80 – 84.1
Decile 9: 84.11 – 88.41
Decile 10: 88.42 – 100

Denominator

Outpatient, telephone, online assessment (i.e. e-visit or virtual check-in), observation, or emergency department (ED) visits with a diagnosis of pharyngitis or tonsillitis and an antibiotic order on or within 3 days after the episode date among patients 3 years or older

Denominator Instructions:

This is an episode of care measure that examines all eligible episodes for the patient during the measurement period. The intent is to determine whether antibiotics are being ordered appropriately. Antibiotics should only be ordered if a strep test has been performed to confirm a bacterial infection. Antibiotics should not be ordered for viral infections. Antibiotics should be ordered on the episode date through three days after the episode date.

An episode is defined as each eligible encounter for patients aged 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic order during the measurement period.

If a patient has more than one eligible episode in a 31-day period, include only the first eligible episode.

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases):

Patients 3 years of age or older on date of encounter

AND

Diagnosis for pharyngitis or tonsillitis (ICD-10-CM): J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91

AND

Patient encounter during the performance period (CPT or HCPCS): 98966, 98967, 98968, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99238, 99239, 99242*, 99243*, 99244*, 99245*, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*

AND

Prescribed antibiotic on or within 3 days after the episode date (Table 1): G8711

AND NOT

DENOMINATOR EXCLUSIONS:

Episodes where the patient is taking antibiotics (Table 1) in the 30 days prior to the episode date, or had an active prescription on the episode date: G9703

OR

Episodes where the patient had a comorbid condition during the 12 months prior to or on the episode date (e.g., tuberculosis, neutropenia, cystic fibrosis, chronic bronchitis, pulmonary edema, respiratory failure, rheumatoid lung disease): G2175

OR

Episodes where the patient had a competing diagnosis within three days after the episode date (e.g., intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, acute sinusitis, chronic sinusitis, infection of the adenoids, prostatitis, cellulitis, mastoiditis, or bone infections, acute lymphadenitis, impetigo, skin staph infections, pneumonia/gonococcal infections, venereal disease (syphilis, chlamydia, inflammatory diseases [female reproductive organs]), infections of the kidney, cystitis or UTI), infections of the kidney, cystitis or UTI): G2097

OR

Patients who use hospice services any time during the measurement period: G9702

Table 1 – Antibiotic Medications
Note: This list should be used when assessing antibiotic prescriptions for the denominator and denominator exclusion components.

Numerator

NUMERATOR:

A group A streptococcus test in the seven-day period from three days prior to the episode date through three days after the episode date

Numerator Instructions:
A higher score indicates appropriate treatment of children with pharyngitis (e.g., the proportion for whom antibiotics were prescribed with an accompanying strep test. The test must be performed to confirm a bacterial infection prior to the antibiotic order).

Numerator Options:

Performance Met:

Group A Strep Test Performed (3210F)

OR

Performance Not Met:

Group A Strep Test not Performed, reason not otherwise specified (3210F with 8P)