CMS Measure ID: #176
Collection Type: CQM
Reporting Frequency: Once per patient per year
High Priority: No
NQS Domain: Effective Clinical Care
Measure Age: > 2 years
This measure is to be submitted a minimum of once per performance period for patients who are being considered or prescribed a first course of biologic and/or immune response modifier therapy seen during the performance period. 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.
If a patient has been newly prescribed a biologic and/or immune response modifier that includes a warning for potential reactivation of a latent infection, then the medical record should indicate TB testing in the preceding 12-month period.
2023 Benchmarks (from 2021 CMS data)
Topped out: Yes
Capped at 7: Yes
Decile 0: 0 – 1.34
Decile 1: 1.35 – 47.05
Minimum: 47.06 – 66.66
Decile 3: 66.67 – 84.51
Decile 4: 84.52 – 95.32
Decile 5: 95.33 – 98
Decile 6: 98.01 – 99.99
Decile 10: 100 – 100
All patients aged 18 years and older who are receiving a first course of therapy using a biologic and/or immune response modifier (such as kinase inhibitors) that includes a warning for potential reactivation of a latent infection
Patients are considered to be receiving a first course of therapy using a biologic and/or immune response modifier that includes a warning for potential reactivation of a latent infection only if they have been prescribed such a biologic and/or immune response modifier during the performance period and also have not been prescribed any such biologic and/or immune response modifier in the 15 months preceding the encounter at which the biologic and/or immune response modifier was newly started. A biologic and/or immune response modifier that includes a warning for potential reactivation of a latent infection includes:
- Adalimumab-adbm (Cyltezo)
- Anakinra (Kineret)
- Brodalumab (Siliq)
Certolizumab pegol and lyophilized certolizumab pegol (CIMZIA)
- Risankizumab-rzaa (Skyrizi)
- Tildrakizumab (Ilumya)
The list of therapies is subject to change as new therapies are approved by the FDA.
To be included in the denominator, patient must have an encounter and a prescription for a biologic and/or immune response modifier in the performance period (1/1/2023-12/31/2023) WITHOUT a prior prescription for a biologic and/or immune response modifier within the 15 months prior to the a biologic and/or immune response modifier prescribed during the performance period.
DENOMINATOR NOTE: *Signifies that this HCPCS 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 the MIPS CQMs.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
Patient encounter during the performance period (CPT or HCPCS): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99424, 99426, G0402, G0468*
Patient receiving first-time biologic and/or immune response modifier therapy: G2182
Patients for whom any record of TB testing is documented or performed (PPD, IFN-gamma release assays, or other appropriate method) in the medical record in the 12 months preceding the biologic and/or immune response modifier prescription.
Performance Met: TB screening performed and results interpreted within twelve months prior to initiation of first-time biologic and/or immune response modifier therapy (M1003)
Denominator Exception: Documentation of medical reason for not screening for TB or interpreting results (i.e., patient positive for TB and documentation of past treatment; patient who has recently completed a course of anti-TB therapy) (M1004)
Performance Not Met: TB screening not performed or results not interpreted, reason not given (M1005)