2026 # 238 MIPS Measure Use of High-Risk Medications in Older Adults

  2026 COLLECTION TYPE:

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

‌MEASURE TYPE: ‌Process – High Priority

• INVERSE MEASURE: LOWER SCORE – BETTER

Description:

Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.

Instructions:

Reporting Frequency:
This measure is to be submitted a minimum of once per performance period 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 aged 65 years of age and older who were ordered at least two high-risk medications. There is no diagnosis associated with this measure. This measure may be submitted by Merit-based 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.

The measure reflects potentially inappropriate medication use in older adults, both for medications where any use is inappropriate and for medications where use under all but specific indications is potentially inappropriate.

Submission Criteria 1:
The intent of the measure is to assess if the eligible clinician ordered high-risk medication(s). The intent of the numerator is to assess if the patient has either been ordered:
• At least two high-risk medications from the same drug class (grouped by row) in Table 1 on different dates of service, or
• At least two high-risk medications from the same drug class (grouped by row) in Table 2 on different dates of service, where the sum of days supply exceeds 90 days
• At least two high-risk medications from the same drug class in Table 3 on different dates of service, each exceeding average daily dose criteria.
If the patient had a high-risk medication previously prescribed by another provider, they would not be counted towards the numerator unless the submitting provider also ordered a high-risk medication for them from the same drug class. Within the medication tables below, a row with one medication is considered a group (or drug class) of one; therefore, two orders of that same medication are numerator compliant.

Submission Criteria 2:
The intent of the numerator is to assess if the patient has been ordered at least two high-risk medications from the same drug class (grouped by row) in Table 4 on different dates of service. The intent of the measure is to assess if the submitting provider ordered the high-risk medication(s). If the patient had a high-risk medication previously prescribed by another provider, they would not be counted towards the numerator unless the submitting provider also ordered a high-risk medication for them from the same drug class.

Measure Strata and Performance Rates:
This measure contains two strata defined by two submission criteria.
This measure produces two performance rates.

There are 2 Submission Criteria for this measure:
1) Patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.
And
2) Patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class, except for appropriate diagnoses.

This measure will be calculated with 2 performance rates:
1) Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.
2) Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class, except for appropriate diagnoses.

For accountability reporting in the CMS MIPS program, the rate for submission criteria 1 is used for performance.

Implementation Considerations:
For the purposes of MIPS implementation, this patient-process measure is submitted a minimum of once per patient during the performance period. The most advantageous quality data code (QDC) will be used if the measure is submitted more than once.

This is an inverse measure which means a lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

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.

SUBMISSION CRITERIA 1: PATIENTS 65 YEARS OF AGE AND OLDER WHO WERE ORDERED AT LEAST TWO HIGH-RISK MEDICATIONS FROM THE SAME DRUG CLASS.

Denominator (Criteria 1):

Patients 65 years and older who had a visit during the measurement period.

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 1(eligible Cases):

Patients aged ≥ 65 years on date of encounter

And

Patient encounter during performance period (CPT or HCPCS): 92002, 92004, 92012, 92014, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015,98016, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99387*, 99397*, G0402, G0438, G0439

And Not

Denominator Exclusions:

Patients who use hospice services any time during the measurement period: G9741

Or

Patients receiving palliative care during the measurement period: G0034

Numerator: Patients whose most recent glycemic status assessment (HbA1c or GMI) (performed during the measurement period) is > 9.0% or is missing, or was not performed during the measurement period.

Numerator Instructions:
Patient is numerator compliant if most recent HbA1c or GMI level >9.0%, the most recent HbA1c or GMI result is missing, or if there are no HbA1c or GMI tests performed and results documented during the measurement period. Ranges and thresholds do not meet criteria for this indicator. A distinct numeric result is required for numerator compliance. Do not include HbA1c or GMI levels reported by the patient

Numerator Note: If multiple glycemic status assessments were recorded for a single date, use the lowest result.

Numerator(Criteria 1):

Patients ordered at least two high-risk medications from the same drug class during the measurement year.

Definitions:
Average Daily Dose – Calculate average daily dose for each prescription event. To calculate average daily dose, multiply the quantity of pills prescribed by the dose of each pill and divide by the days supply. For example, a prescription for the 30-days supply of digoxin containing 15 pills, 0.25 mg each pill, has an average daily dose of 0.125 mg. To calculate average daily dose for elixirs and concentrates, multiply the volume prescribed by daily dose and divide by the days supply. Do not round when calculating average daily dose. Cumulative Medication Duration – an individual’s total number of medication days over a specific period; the period counts multiple prescriptions with gaps in between, but does not count the gaps during which a medication was not dispensed.

To determine the “cumulative medication duration”, determine first the number of the Medication Days for each prescription in the period: the number of doses divided by the dose frequency per day. Then add the Medication Days for each prescription without counting any days between the prescriptions.

For example, there is an original prescription for 30 days with 2 refills for thirty days each. After a gap of 3 months, the medication was ordered again for 60 days with 1 refill for 60 days. The “cumulative medication duration” is (30 x 3) + (60 x 2) = 210 days over the 10 month period.

Reference Coding/Medication:

Numerator Option for At least two orders for high-risk medications [G9368] is defined by the following tables (1, 2, and 3), however, this measure aligns with the eCQM measure (CMS 156) and providers may review the RxNorm codes in the applicable eCQM value sets for submission.

Table 1 – High-Risk Medications at any Dose or Duration

Description	Prescription
Anticholinergics, first-generation antihistamines	Brompheniramine    Diphenhydramine Chlorpheniramine   (oral) Doxylamine Cyproheptadine     Hydroxyzine Dimenhydrinate     Meclizine Promethazine     Triprolidine
Anticholinergics, anti-Parkinson agents	Benztropine (oral)     Trihexyphenidyl
Antispasmodics	Atropine (exclude ophthalmic)    Hyoscyamine Chlordiazepoxideclidinium         Scopolamine Dicyclomide
Antithrombotics	Dipyridamole, (oral, excluding extended release)
Cardiovascular, alpha agonists, centra	Guanfacine
Cardiovascular, other	Nifedipine (excluding extended release)
Central nervous system, antidepressants	Amitriptyline    Imipramine Amoxapine    Nortriptyline Clomipramine    Paroxetine Desipramine
Central nervous system, barbiturates	Butalbital  Phenobarbital Primidone
Central nervous system, vasodilators	Ergoloid mesylates
Central nervous system, other	Meprobamate
Endocrine system, estrogens with or without progestins; include only oral and topical patch products	Conjugated estrogen Esterified estrogen Estradiol Estropipate
Endocrine system, sulfonylureas, longduration	Glimepiride      Glyburide
Endocrine system, desiccated thyroid	Desiccated thyroid
Endocrine system, megestro	Megestrol
Nonbenzodiazepine hypnotics	EszopicloneZaleplon      Zolpidem
Pain medications, skeletal muscle relaxants	Carisoprodol    Metaxalone Chlorzoxazone    Methocarbamol Cyclobenzaprine    Orphenadrine
Pain medications, meperidine	Meperidine
Pain medications, other	Indomethacin    Ketorolac, includes parenteral and oral

*The registry version of the measure specifications only indicates the classes of drugs that are considered high-risk and do not include the specific coding of RxNorm. However, this measure aligns with the eCQM measure (CMS 156) and providers may review the RxNorm codes in the applicable eCQM value sets for submission.
**A row with one medication is considered a group (or drug class) of one; therefore, two orders of that same medication are numerator compliant.

Table 2 – High-Risk Medications With Days Supply Criteria

Description	Prescription	Days Supply Criteria
Anti-Infectives, other	Nitrofurantoin    Nitrofurantoin acrocrystals-monohydrate	> 90 days

 

Table 3 – High-Risk Medications With Average Daily Dose Criteria

Description	Prescription	Average Daily Dose Criteria
Cardiovascular, other	Digoxin	> 0.125 mg per day
Tertiary tricyclic antidepressants (TCAs) (as single agent or as part of combination products)	Digoxin	> 6 mg per day

Numerator Instructions:
A high-risk medication is identified by either of the following:
• A prescription for medications classified as high risk at any dose and for any duration listed in Table 1
• Prescriptions for medications classified as high risk at any dose with greater than a 90 day cumulative medication duration listed in Table 2
• A prescription for medications classified as high risk exceeding average daily dose criteria listed in Table 3

NUMERATOR NOTE:
The goal of this measure is to identify any patient that has been prescribed two high-risk medications. As such, patients are to be counted as numerator-compliant regardless of the condition(s) for which the medications are ordered.

Numerator Options:

Performance Not Met: At least two orders for high-risk medications from the same drug class not ordered (G9368)

Or

Performance Met: At least two orders for high-riskmedications from the same drug class (G9367)

And

SUBMISSION CRITERIA 2: PATIENTS 65 YEARS OF AGE AND OLDER WHO WERE ORDERED AT LEAST TWO HIGH-RISK MEDICATIONS FROM THE SAME DRUG CLASS, EXCEPT FOR APPROPRIATE DIAGNOSES

Denominator (Criteria 2):

Patients 65 years and older who had a visit during the measurement period.

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:
Patients aged ≥ 65 years on date of encounter

And

Patient encounter during performance period (CPT or HCPCS): 92002, 92004, 92012, 92014, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015,98016, 99202, 99203, 99204, 99205,99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99387*, 99397*, G0402, G0438, G0439

And Not

DENOMINATOR EXCLUSIONS:
Patients who use hospice services any time during the measurement period: G9741
Or
Patients receiving palliative care during the measurement period: G0034

Numerator(Criteria 2):

Patients with at least two orders of high-risk medications from the same drug class (i.e., antipsychotics and benzodiazepines), except for appropriate diagnoses.

Definitions:
Index Prescription Start Date (IPSD) – The start date of the earliest prescription ordered for a high-risk medication during the measurement period.

Reference Coding/Medication:

Numerator Option for At least two orders for high-risk medications [M1209] is defined by the following table 4, however, this measure aligns with the eCQM measure (CMS 156) and providers may review the RxNorm codes in the applicable eCQM value sets for submission

Table 4 – High-Risk Medications

Description	Prescription
Antipsychotics, first (conventional) and second (atypical) generation	Aripiprazole      Molindone Aripiprazole lauroxil     Olanzapine Asenapine     Paliperidone Brexpiprazole   Perphenazine Cariprazine   Pimavanserin Chlorpromazine    Pimozide Clozapine    Quetiapine Fluphenazine    Risperidone Haloperidol    Thioridazine Iloperidone    Thiothixene Loxapine    Trifluoperazine Lurasidone    Ziprasidone
Benzodiazepines, long, short and intermediate acting	Alprazolam     Lorazepam Chlordiazepoxide   Midazolam Clobazam    Oxazepam Clonazepam Temazepam Clorazepate    Triazolam Diazepam Estazolam

*The registry version of the measure specifications only indicates the classes of drugs that are considered high-risk and do not include the specific coding of RxNorm. However, this measure aligns with the eCQM measure (CMS 156) and providers may review the RxNorm codes in the applicable eCQM value sets for submission.

Numerator Instructions:
A high-risk medication is identified by:
• A prescription for medications classified as high risk at any dose and for any duration listed in Table 4

Numerator Options:
Performance Not Met: At least two orders for high-risk medications from the same drug class, (Table 4), not ordered (M1210)

Or

Performance Not Met: Two or more antipsychotic prescriptions ordered for patients who had a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder on or between January 1 of the year prior to the measurement period and the Index Prescription Start Date (IPSD) for antipsychotics (G0032)

Or

Performance Not Met: Two or more benzodiazepine prescriptions ordered for patients who had a diagnosis of seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, or severe generalized anxiety disorder on or between January 1 of the year prior to the measurement period and the IPSD for benzodiazepines (G0033)

Or

Performance Met: At least two orders for high-risk medications from the same drug class, (Table 4), without appropriate diagnoses (M1209)

Rationale:

Certain medications (MacKinnon & Hepler, 2003) are associated with increased risk of harm from drug side-effects and drug toxicity and pose a concern for patient safety. There is clinical consensus that these drugs pose increased risks in older adults (Kaufman, Brodin, & Sarafian, 2005). Potentially inappropriate medication (PIM) use in older adults has been connected to significantly longer hospital stay lengths and increased hospitalization costs (Hagstrom et al., 2015) as well as increased risk of death (Lau et al. 2004). Use of specific high-risk medications such as hypnotics, including benzodiazepine receptor agonists, and nonsteroidal anti-inflammatory drugs (NSAIDS) can result in increased risk of delirium, falls, fractures, gastrointestinal bleeding and acute kidney injury (Merel et al., 2017). Long-term use of benzodiazepines in older adults has been associated with increased risk of dementia (Zhong et al., 2015; Takada et al., 2016). Additionally, the use of antipsychotics can lead to increased risk of stroke and greater cognitive decline in older adults with dementia (Tampi et al., 2016). Among Medicare beneficiaries it is estimated that the prevalence of PIM use was 77% among long-stay nursing home residents (defined as >101 consecutive days in a nursing home). The most common PIMs were benzodiazepines, antipsychotics, and insulin (Riester et al., 2023).

Older adults receiving inappropriate medications are more likely to report poorer health status at follow-up, compared to those who receive appropriate medications (Lau et al. 2004). A study of the prevalence of potentially inappropriate medication use in older adults found that 40 percent of individuals 65 and older filled at least one prescription for a potentially inappropriate medication and 13 percent filled two or more (Fick et al. 2008). While some adverse drug events (ADEs) are unavoidable, studies estimate that between 30 and 80 percent of ADEs in older adults are preventable (MacKinnon and Hepler 2003). More recently with the onset of the COVID-19 pandemic, several studies have shown an increase in anxiety, insomnia and depression rates, which could result in an increase in the use of high-risk medications in order to treat these conditions (Agrawal, 2020).

Reducing the number of inappropriate prescriptions can lead to improved patient safety and significant cost savings. Conservative estimates of extra costs due to potentially inappropriate medications in older adults average $7.2 billion a year (Fu et al. 2007). Medication use by older adults will likely increase further as the U.S. population ages, new drugs are developed, and new therapeutic and preventive uses for medications are discovered (Rothberg et al. 2008). The annual direct costs of preventable ADEs in the Medicare population have been estimated to exceed $800 million (IOM, 2007). By the year 2030, nearly one in five U.S. residents is expected to be aged 65 years or older; this age group is projected to more than double from 38.7 million in 2008 to more than 88.5 million in 2050. Likewise, the population aged 85 years or older is expected to increase almost four-fold, from 5.4 million to 19 million between 2008 and 2050. As the older adult population continues to grow, the number of older adults who present with multiple medical conditions for which several medications are prescribed will likely continue to increase, resulting in polypharmacy concerns (Gray and Gardner 2009)