2021 MIPS Measure #066: Appropriate Testing for Children with Pharyngitis

Measure Description

The percentage of episodes for patients 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic dispensing event and a group A streptococcus (strep) test

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 dispensed 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:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. 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 by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

Denominator

Outpatient, telephone, online assessment, observation, or emergency department (ED) visits with a diagnosis of pharyngitis and an antibiotic dispensing event 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. 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 (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, 99217, 99218, 99219, 99220, 99241*, 99242*, 99243*,99244*, 99245*, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*,99396*, 99397*

AND

Prescribed or dispensed antibiotic: G8711

AND NOT

DENOMINATOR EXCLUSIONS:

Episodes where the patient is taking antibiotics (Table 1) in the 30 days prior to the episode date: G9703

OR

Episodes where the patient had a competing 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): G2097

OR

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

Table 1 – Antibiotic Medications

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 step test).

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)