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2023 # 464 Otitis Media with Effusion: Systemic Antimicrobials – Avoidance of Inappropriate Use


CMS Measure ID: #464

Collection Type: CQM

Reporting Frequency: Once per episode of treatment

Outcome: No

High Priority: Yes

NQS Domain: Person and Caregiver-Centered Experience Outcomes

Measure Age: > 2 years


This measure is to be submitted once for each occurrence of otitis media with effusion (OME) in children seen during the performance period. Each unique occurrence is defined as a 90-day period from onset of OME. If multiple occurrences are documented within a 90-day period, eligible clinicians should submit one instance.

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.


Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials

2023 Benchmarks (from 2021 CMS data)


Topped out: Yes
Capped at 7: Yes

Decile 0: 0 – 5.87
Decile 1: 5.88 – 69.99
Minimum: 70 – 83.55
Decile 3: 83.56 – 88.82
Decile 4: 88.83 – 95.05
Decile 5: 95.06 – 97.07
Decile 6: 97.08 – 98.2
Decile 7: 98.21 – 99.99
Decile 10: 100 – 100


All patients aged 2 months through 12 years with a diagnosis of OME

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 2 months through 12 years on the date of the encounter 


Diagnosis for OME (ICD-10-CM):  

H65.90, H65.91, H65.92, H65.93, H65.111, H65.112, H65.113, H65.114, H65.115, H65.116, H65.117, H65.119, H65.191, H65.192, H65.193, H65.194, H65.195, H65.196, H65.197, H65.199, H65.411, H65.412, H65.413, H65.419, H65.491, H65.492, H65.493, H65.499


Patient encounter during the performance period (CPT):

99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99381*, 99382*, 99383*, 99384*, 99391*, 99392*, 99393*, 99394*



Patients who were not prescribed systemic antimicrobials

Numerator Instructions:
For performance, the measure will be calculated as the number of patients for whom systemic antimicrobials were neither prescribed nor recommended over the number of patients in the denominator (patients aged 2 months through 12 years with a diagnosis of OME). A higher score indicates appropriate treatment of patients with OME (e.g., the proportion for whom systemic antimicrobials were not prescribed). 

Numerator Options:

Performance Met:

Systemic antimicrobials not prescribed (G9959)


Denominator Exception:

Documentation of medical reason(s) for prescribing systemic antimicrobials (G9960)


Performance Not Met:

Systemic antimicrobials prescribed (G9961)

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