2026 #277 MIPS Measure Sleep Apnea: Severity Assessment at Initial Diagnosis

‌2026 COLLECTION TYPE:

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

‌MEASURE TYPE:

Process

‌DESCRIPTION:

Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI), a respiratory disturbance index (RDI), or a respiratory event index (REI) documented or measured within 2 months after initial evaluation for suspected obstructive sleep apnea.

‌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:

The intent of this measure is to ensure appropriate evaluation of patients with a diagnosis of obstructive sleep apnea. 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.

‌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 each time a patient has a denominator eligible encounter 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:

All patients aged 18 years and older with an initial diagnosis of sleep apnea

‌DENOMINATOR NOTE:

Denominator eligible encounters only include those where the initial diagnosis of sleep apnea is present in the medical documentation or it is the MIPS eligible clinician’s first encounter with a patient diagnosed with sleep apnea as represented in the coding below.

‌Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter

AND

Diagnosis for sleep apnea on date of encounter (ICD-10-CM): G47.30, G47.33

AND

Patient encounter during the performance period (CPT): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350

AND

Encounter corresponds to initial diagnosis of sleep apnea or first contact with sleep apnea diagnosed patient: M1441

‌NUMERATOR:

Patients who had an apnea hypopnea index (AHI), a respiratory disturbance index (RDI), or a respiratory event index (REI) documented or measured within 2 months after initial evaluation for suspected obstructive sleep apnea

‌Definitions:

Apnea-Hypopnea Index (AHI) – for polysomnography performed in a sleep lab is defined as (Total Apneas + Hypopneas per hour of sleep); “Apnea-Hypopnea Index (AHI)” for a home sleep study is defined as (Total Apneas + Hypopneas per hour of monitoring).

Respiratory Disturbance Index (RDI) – is defined as (Total Apneas + Hypopneas + Respiratory Effort Related Arousals per hour of sleep).

Respiratory Event Index (REI) – is a measure of respiratory events per unit of time for a home sleep apnea test.

‌NUMERATOR NOTE:

The quality data codes below should be used for assessment of a MIPS eligible clinician’s actions within 2 months after the initial evaluation for obstructive sleep apnea. If there is not adequate time for measuring an apnea hypopnea index (AHI), a respiratory disturbance index (RDI), or a respiratory event index (REI) (e.g., initial evaluation was conducted in December of the performance period), report the denominator exception.

‌Numerator Options:

‌Performance Met: Apnea hypopnea index (AHI), respiratory disturbance index (RDI) or respiratory event index (REI) documented or measured within 2 months after initial evaluation for suspected obstructive sleep apnea (G8842)

OR

‌Denominator Exception: Documentation of reason(s) for not measuring an apnea hypopnea index (AHI), a respiratory disturbance index (RDI), or a respiratory event index (REI) within 2 months after initial evaluation for suspected obstructive sleep apnea (e.g., medical, neurological, or psychiatric disease that prohibits successful completion of a sleep study, patients for whom a sleep study would present a bigger risk than benefit or would pose an undue burden, dementia, patients previously diagnosed with OSA and severity assessed by another provider, patients who decline AHI/RDI/REI measurement, patients who had a financial reason for not completing testing, test was ordered but not completed, patients decline because their insurance (payer) does not cover the expense) (G8843)

‌OR

Performance Not Met: Apnea hypopnea index (AHI), respiratory disturbance index (RDI), or respiratory event index (REI) not documented or measured within 2 months after initial evaluation for suspected obstructive sleep apnea, reason not given (G8844)

RATIONALE:

The severity of OSA must be established in order to make an appropriate treatment decision. For patients with obstructive sleep apnea (OSA), treatment selection and implementation are dependent on the severity of the disease. Physicians treating patients with OSA should calculate the patient’s level of severity, which informs risk for other comorbid conditions and complications. Clinically, the apnea-hypopnea index (AHI) provides cutpoints that can be used to establish the diagnosis and severity of OSA and evaluate treatment effect (Cielo et al, 2019). OSA severity is graded depending on the AHI. Mild OSA with AHI of 5 to <15, moderate with AHI of 15 to 30 and severe with AHI of >30 (Soori et al, 2022). Patients with a respiratory disturbance index equal to or greater than 15 are considered to have moderate to severe OSA and should be treated with OSA therapy.