2026 # 065 MIPS Measure Appropriate Treatment for Upper Respiratory Infection (URI)

2026 COLLECTION TYPE:

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

‌MEASURE TYPE:‌ Process – High Priority

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.

Instructions:

Reporting Frequency:
This measure is to be submitted once for each occurrence for denominator eligible cases as defined in the denominator criteria.

Intent and Clinician Applicability:
This measure is intended to reflect the quality of services provided for patients with a diagnosis of upper respiratory infection (URI). Claims data will be analyzed to determine unique occurrences. This measure may be submitted by Meritbased 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 one strata defined by a single submission criteria.
This measure produces a single performance rate.

Implementation Considerations:
For the purposes of MIPS implementation, this episode measure is submitted once for each occurrence of a particular illness or condition during 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

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) from January 1 to December 28 for patients 3 months of age and older.

Denominator Instructions: 
This is an episode of care measure that examines all eligible episodes for the patient. If the patient has more than one episode in a 31-day period, include only the first episode. An episode is defined as each eligible encounter for patients aged 3 months of age and older with a diagnosis of upper respiratory infection during the measurement period of January 1 to December 28.

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 measurement period (CPT or HCPCS): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98966, 98967, 98968,98979, 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*, 99421, 99422, 99423, , 99455, 99456, 99457, 99470, 98980, G2250, G2251, G2252

Without

Place of Service (POS): 21

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

Reference Coding/Medication:
Table 1: Denominator Exclusion for a dispense medication for dementia [G2090] is defined by the following Dementia Medications only:

Note: This list should be used when assessing antibiotic prescriptions for the denominator exclusion and
numerator components.

Numerator:

URI episodes without a prescription for antibiotic medication (Table 1) on or within 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)

Rationale:

‌Most upper respiratory infections (URI), also known as the common cold, are caused by viruses that require no antibiotic treatment. Too often, antibiotics are prescribed inappropriately, which can lead to antibiotic resistance (when antibiotics can no longer cure bacterial infections). In the United States, at least 2.8 million antibiotic-resistant illnesses and 35,000 deaths occur each year (CDC, 2020).