2023 # 065 Appropriate Treatment for Upper Respiratory Infection (URI)

CMS Measure ID: #65

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 upper respiratory infection during the performance period. Claims data will be analyzed to determine unique occurrences. 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

Percentage of episodes for patients 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic order

2023 Benchmarks (from 2021 CMS data)

eCQM

Topped out: No
Capped at 7: No

Decile 0: 0 – 37.09
Decile 1: 37.1 – 77.49
Minimum: 77.5 – 86.66
Decile 3: 86.67 – 90.11
Decile 4: 90.12 – 92.79
Decile 5: 92.8 – 94.73
Decile 6: 94.74 – 96.25
Decile 7: 96.26 – 97.77
Decile 8: 97.78 – 99.24
Decile 9: 99.25 – 99.99
Decile 10: 100 – 100

Denominator

Outpatient visits, telephone visits, online assessments (i.e. e-visit or virtual check-in), observation stays or emergency department visits with a diagnosis of upper respiratory infection (URI) during the measurement period among patients 3 months of age and older.

Denominator Instructions:

This is an episode of care measure that examines all eligible episodes for the patient during the measurement period. If the patient has more than one episode in a 31-day period, include only the first 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 aged 3 months of age and older on date of encounter

AND

Diagnosis for URI (ICD-10-CM): J00, J06.0, J06.9

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, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99441, 99442, 99443, 99455, 99456

AND NOT

DENOMINATOR EXCLUSIONS:

URI 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): G2173

OR

URI episodes when the patient had an active prescription of antibiotics (Table 1) in the 30 days prior to the episode date or is still active the same day of the encounter: G2174

OR

URI episodes when the patient had competing diagnoses on or three days after the episode date (e.g., intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, acute sinusitis, acute pharyngitis, acute tonsillitis, chronic sinusitis, infection of the pharynx/larynx/tonsils/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, and acne): G8709

OR

Patients who use hospice services any time during the measurement period: G9700

Table 1 – Antibiotic Medications

Numerator

URI episodes without a prescription for antibiotic medication (Table 1) on or 3 days after the outpatient visit, telephone visit, online assessment, observation stay or emergency department visit for an upper respiratory infection

Numerator Instructions:

For performance, the measure will be calculated as the number of patient’s encounter(s) where antibiotics from Table 1 were not prescribed on or within three days of the episode for URI over the total number of encounters in the denominator. A higher score indicates appropriate treatment of patients with URI (e.g., the proportion for whom antibiotics were not prescribed following the episode). Delayed prescriptions (where an antibiotic was prescribed and patient was instructed to delay taking the antibiotic) are considered “Performance Not Met”.

Numerator Options:

Performance Met: Patient not prescribed antibiotic (G8708)

OR

Performance Not Met: Patient prescribed antibiotic (G8710)