2026 # 066 Appropriate Testing for Pharyngitis

2026 COLLECTION TYPE:

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

‌MEASURE TYPE:‌ Process – High Priority

Description:

‌The percentage of episodes for patients 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic order on or within 3 days after the episode date and a group A Streptococcus (Strep) test in the seven-day period from three days prior to the episode date through three days after the episode date.

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 the primary management of patients with a diagnosis of pharyngitis who were ordered an antibiotic. 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.

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 of this measure, 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, telephone, online assessment (i.e., e-visit or virtual check-in), observation, or emergency department (ED) visits with a diagnosis of pharyngitis or tonsilitis from January 1 to December 28 and an antibiotic order on or within 3 days after the episode date among patients 3 years or older.

Denominator Instructions: 
This is an episode of care measure that examines all eligible episodes for the patient. The intent is to determine whether antibiotics are being ordered appropriately. Antibiotics should only be ordered if a strep test has been performed to confirm a bacterial infection. Antibiotics should not be ordered for viral infections. Antibiotics should be ordered on the episode date through three days after the episode date.

An episode is defined as each eligible encounter for patients aged 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic order during the measurement period of January 1 to December 28. 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 or tonsillitis (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 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, 99242*, 99243*, 99244*, 99245*, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, 99421, 99422, 99423, 99457, 99470, 98980, G2250, G2251, G2252

Without

Place of Service (POS): 21

And

Prescribed antibiotic on or within 3 days after the episode date (Table 1): 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 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 on or 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

Reference Medication Table:
Table 1 – Denominator Exclusion for Taking Antibiotics [G9703] is defined by the following antibiotic medications only:

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

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 Strep test. The test must be performed to confirm a bacterial infection prior to the antibiotic order)

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)

Rationale:

‌Group A streptococcal (GAS) bacterial infections and other infections that cause pharyngitis (which are most often viral) often produce the same signs and symptoms (Shulman et al., 2012). The American Academy of Pediatrics, the Centers for Disease Control and Prevention, and the Infectious Diseases Society of America all recommend a diagnostic test for Strep A to improve diagnostic accuracy and avoid unnecessary antibiotic treatment (Linder et al. 2005). Estimated economic costs of pediatric streptococcal pharyngitis in the United States range from $224 million to $539 million per year, including indirect costs related to parental work losses. At a higher level, the economic cost of antibiotic resistance vary but have extended as high as $20 billion in excess direct healthcare costs, with additional costs to society for lost productivity as high as $35 billion a year (2008 dollars) (Pfoh et al., 2008