2026 #400 MIPS Measure One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation

2026 COLLECTION TYPE:

MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)

‌MEASURE TYPE:

Process

‌DESCRIPTION:

Percentage of patients aged ≥ 18 years who have never been tested for Hepatitis C Virus (HCV) infection who receive an HCV infection test AND who have treatment initiated within three months or who are referred to a clinician who treats HCV infection within one month if tested positive for HCV.

‌INSTRUCTIONS:‌

Reporting Frequency:

This measure is to be submitted a minimum of once per performance period for denominator eligible cases as defined in the denominator criteria.

‌Intent and Clinical Applicability

This measure is intended to reflect the quality of service provided for patients age 18 years and older who were seen twice for any visits or who had at least one preventive visit through September 30 of the performance period AND who have never received an HCV antibody test. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions as defined by the numerator based on the services provided and the measure-specific denominator coding.

‌Measure Strata and Performance Rates:

This measure contains two strata defined by two submission criteria. This measure produces two performance rates.

There are 2 Submission Criteria for this measure:

1. All patients aged ≥ 18 years who have never been tested for HCV antibodies and who receive an HCV antibody test.

AND

1. All patients aged ≥ 18 years who have a reactive (positive) HCV antibody test and have a follow up HCV viral test, and if HCV viremia is detected, have treatment initiated within three months or are referred to a clinician who treats HCV infection within one month of the reactive HCV antibody test.

This measure contains two submission criteria that aim to identify patients who are tested for HCV antibodies (Submission Criteria 1) and patients who have a reactive HCV antibody test and who have a follow up HCV viral test, and if HCV viremia is detected, have treatment initiated within three months or are referred to a clinician who treats HCV infection within one month of the reactive HCV antibody test (Submission Criteria 2). By separating this measure into various submission criteria, the MIPS eligible clinician will be able to better ascertain where gaps in performance exist and identify opportunities for improvement.

This measure will be calculated with 2 performance rates:

1. Percentage of patients aged ≥ 18 years who have never been tested for HCV antibodies and who receive an HCV antibody test.
2. Percentage of patients aged ≥ 18 years who have a reactive HCV antibody test, who have a follow up HCV viral test, and if HCV viremia is detected, have treatment initiated within three months or are referred to a clinician who treats HCV infection within one month of the reactive HCV antibody test.

A simple average, which is the sum of the performance rates divided by the number of the performance rates will be used to calculate performance.

‌Implementation Considerations:

For the purposes of MIPS implementation of this measure, this patient-process measure is submitted a minimum of once per patient during the performance period. The most advantageous quality data code will be used if the measure is submitted more than once.

The denominator of Submission Criteria 2 is a subset of the resulting numerator for Submission Criteria 1, as Submission Criteria 2 is limited to assessing if patients who have a reactive HCV antibody test, have a follow up HCV viral test, and if HCV viremia is detected, treatment is initiated within three months or they are referred to a clinician who treats HCV infection within one month of the reactive HCV antibody test. For all patients aged ≥ 18 years who have never been tested for HCV antibodies, Submission Criteria 1 is applicable, but Submission Criteria 2 will only be applicable for those patients who have a reactive HCV antibody test.

Include only eligible encounters and HCV antibody test results documented through September 30 of the performance period. This will allow the evaluation of at least 90 days for treatment initiation or documentation of referral made within the performance period.

‌Telehealth:

TELEHEALTH ELIGIBLE: This measure is appropriate for and applicable to the telehealth setting. Patient encounters conducted via telehealth using encounter code(s) found in the denominator encounter criteria are allowed for this measure. Therefore, if the patient meets all denominator criteria for a telehealth encounter, it would be appropriate to include them in the denominator eligible patient population. Telehealth eligibility is at the measure level for inclusion within the denominator eligible patient population and based on the measure specification definitions which are independent of changes to coding and/or billing practices.

‌Measure Submission:

The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this collection type for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. The coding provided to identify the measure criteria: Denominator or Numerator, may be an example of coding that could be used to identify patients that meet the intent of this clinical topic. When implementing this measure, please refer to the ‘Reference Coding’ section to determine if other codes or code languages that meet the intent of the criteria may also be used within the medical record to identify and/or assess patients. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

SUBMISSION CRITERIA 1: PATIENTS WHO HAVE NEVER BEEN TESTED FOR HCV ANTIBODIES AND WHO RECEIVE AN HCV ANTIBODY TEST

‌DENOMINATOR (CRITERIA 1):

All patients aged ≥ 18 years who are seen twice for any visits or who have at least one preventive visit between January 1 and September 30 of the performance period.

‌DENOMINATOR NOTE:

Either documentation of the prior HCV antibody test or HCV RNA test in the medical record or patient self-report of prior HCV antibody test or HCV RNA test is acceptable for this exclusion.

*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 1(Eligible Cases):

Patients aged ≥ 18 years

AND

At least one preventive encounter (CPT or HCPCS): 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, G0438, G0439

OR

At least two patient encounters (CPT): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350

AND NOT

DENOMINATOR EXCLUSION:

Diagnosis for Chronic Hepatitis C during the performance period: M1461

OR

Documentation or patient report of HCV antibody test or HCV RNA test which occurred prior to the performance period: M1235

‌Reference Coding:

Denominator Exclusion for Chronic Hepatitis C [M1461] is defined by the following coding only: B18.2

‌NUMERATOR (CRITERIA 1):

Patients who receive an HCV antibody test between January 1 and September 30 of the performance period.

‌NUMERATOR NOTE:

Denominator Exception(s) are determined on the date of the most recent denominator eligible encounter.

‌Numerator Options:

‌Performance Met: Patient receives HCV antibody test with nonreactive result (M1231)

OR

‌Performance Met: Patient receives HCV antibody test with reactive result (M1232)

OR

‌Denominator Exception: Documentation of medical reason(s) for not receiving HCV antibody test due to limited life expectancy (G9452)

‌OR

Performance Not Met: Patient does not receive HCV antibody test OR patient does receive HCV antibody test but results not documented, reason not given (M1233)

AND

SUBMISSION CRITERIA 2: PATIENTS WITH A REACTIVE (POSITIVE) HCV ANTIBODY TEST WITH A FOLLOW UP HCV VIRAL TEST, AND IF HCV VIREMIA IS DETECTED, TREATMENT IS INITIATED WITHIN THREE MONTHS OR RECEIVES A REFERRAL TO A CLINICIAN WHO TREATS HCV INFECTION WITHIN ONE MONTH OF THE REACTIVE HCV ANTIBODY TEST

‌DENOMINATOR (CRITERIA 2):

Patients aged ≥ 18 years who are seen twice for any visits OR who have at least one preventive visit AND have documentation of a reactive HCV antibody test between January 1 and September 30 of the performance period.

‌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 2(Eligible Cases):

Patients aged ≥ 18 years

AND

All eligible instances when M1232 is submitted for Performance Met (patient receives HCV antibody test and the test is reactive) in the numerator of Submission Criteria 1

AND

At least one preventive encounter (CPT or HCPCS): 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, G0438, G0439

OR

At least two patient encounters (CPT): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350

‌NUMERATOR (CRITERIA 2):

Patients who have an HCV viral test conducted that (a) does not detect HCV viremia, or (b) detects HCV viremia and treatment is initiated within three months or they are referred to a clinician who treats HCV infection within one month of the reactive HCV antibody test.

‌Definitions:

Examples of clinicians who treat HCV infection include but are not limited to –

• Gastroenterologist
• Hepatologist
• Infectious disease clinicians

Initiation of treatment definition for clinicians who do not refer patients to specialists for care – Initiation of antiviral treatment, as appropriate, based on clinical guideline recommendations and patient characteristics.

HCV viral test – is defined as a test measuring an established marker of active HCV infection, including:

• HCV RNA test
• HCV core antigen test

‌Numerator Options:

‌Performance Met: Patient, who has a reactive HCV antibody test, and has a follow up HCV viral test that detected HCV viremia, is referred within 1 month of the reactive HCV antibody test to a clinician who treats HCV infection (M1229)

OR

‌Performance Met: Patient, who has a reactive HCV antibody test, and has a follow up HCV viral test that detected HCV viremia, has HCV treatment initiated within 3 months of the reactive HCV antibody test (M1228)

‌OR

Performance Met: Patient has a reactive HCV antibody test, and has a follow up HCV viral test that does not detect HCV viremia (M1234)

OR

‌Performance Not Met: Patient has a reactive HCV antibody test and does not have a follow up HCV viral test, OR Patient has a reactive HCV antibody test and has a follow up HCV viral test that detects HCV viremia and is not referred to a clinician who treats HCV infection within 1 month and does not have HCV treatment initiated within 3 months of the reactive HCV antibody test, reason not given (M1230)

RATIONALE:

Of the estimated 3.5 million people living in the United States with the hepatitis C virus infection (HCV), only 50% have been tested for HCV and are aware of their status. Reported cases of HCV have increased (approximately 20% per year) between 2010 – 2016 which is partially due to improved case detection and more likely due to rising rates of injection drug use. Additionally, only one third have been referred for HCV care and only 5.6% receive recommended treatment. Studies indicate that even among high-risk patients for whom screening is recommended, only 49-75% are aware of their infection status. In a recent analysis of data from a national health survey, 67.9% of persons ever infected with HCV reported an exposure risk (e.g., injection drug use, having sexual contact with suspected/confirmed hepatitis C patient), 2 weeks to 6 months prior to symptom onset, and the remaining 32.1% reported no known exposure risk. Current risk-based testing strategies have had limited success, as evidenced by the substantial number of HCV-infected persons who remain unaware of their infection. As a result, many do not receive needed care (e.g., education, counseling, and medical monitoring), and are not evaluated for treatment. HCV causes acute infection, which can be characterized by mild to severe illness but is usually asymptomatic. In approximately 75%-85% of persons, HCV persists as a chronic infection, placing infected persons at risk for liver cirrhosis, hepatocellular carcinoma (HCC), and extrahepatic complications that develop over the decades following onset of infection. HCV testing is the first step toward improving health outcomes for persons infected with HCV. The CDC and AASLD suggest one time screening for all patients aged 18 years or older and there is limited evidence to support the upper age limit suggested by the USPSTF of 79 years of age; therefore, we recommend one-time screening for HCV infection in all patients aged 18 years and older consistent with the evidenced based guidance.