2026 #279 MIPS Measure Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) Therapy

‌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 (OSA) that were prescribed an evidence-based therapy that had documentation that adherence to therapy was assessed at least annually through an objective informatics system or through self-reporting (if objective reporting is not available).

‌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 with OSA. 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 patient-process measure is submitted a minimum of once per patient during the performance period. The most advantageous quality data code will be used if the measure is submitted more than once.

‌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 a diagnosis of obstructive sleep apnea who were prescribed an evidence-based therapy.

‌Definition:

Evidence-based Therapy – includes positive airway pressure, oral appliances, positional therapies, hypoglossal nerve stimulation, or other devices with monitoring capabilities.

‌Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter

AND

Diagnosis for obstructive sleep apnea on date of encounter (ICD-10-CM): 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

Evidence-based therapy was prescribed: M1227

‌NUMERATOR:

Patients with documentation that adherence to therapy was assessed at least annually through an objective informatics system or through self-reporting (if objective reporting is not available).

‌Definitions:

Documentation of adherence to therapy – includes a note documented in the patient’s medical record that patient is adherent to the prescribed therapy for obstructive sleep apnea.

Objective Informatics – a telemonitoring system that shows data demonstrating patient adherence to the prescribed therapy for obstructive sleep apnea (i.e., CPAP machines with SD cards that store data).

Objective Reporting – data that are reported from an objective informatics or other data source and is not reported by the patient or parent/caregiver.

Self-Reporting – patient and/or parent/caregiver attests to compliance with prescribed therapy for obstructive sleep apnea, which is documented in the medical record.

‌Numerator Options:

‌Performance Met: Adherence to therapy was assessed at least annually through an objective informatics system or through self-reporting (if objective reporting is not available, documented) (G8851)

‌OR

Denominator Exception: Documentation of reason(s) for not objectively reporting adherence to evidence-based therapy (e.g., patients who have been diagnosed with a terminal or advanced disease with an expected life span of less than 6 months, patients who decline therapy, patients who do not return for follow-up at least annually, patients unable to access/afford therapy, patient’s insurance will not cover therapy) (G8854)

‌OR

Performance Not Met: Adherence to therapy was not assessed at least annually through an objective informatics system or through self-reporting (if objective reporting is not available), reason not given (G8855)

RATIONALE:

This recommendation is based on evidence that therapy adherence is extremely important for patients with OSA to experience improvement in signs and symptoms of OSA. Although positive airway pressure (PAP) has been the most efficacious therapy and is often the first option for OSA patients. For patients with mild or moderate OSA, oral appliances may also be appropriate therapy. However, some patients find such devices to be intrusive, inconvenient, or intolerable. Surgical modification of the upper airway is also a viable treatment for selected patients (Morgenthaler, 2006).

Under ideal circumstances, patients with inadequate PAP utilization will have had an opportunity to consult with a sleep medicine professional to address barriers to adherence, although access to such resources may be limited in some areas. A threshold for adequate PAP adherence will vary between patients depending on their individual underlying medical history, symptomatology, disease severity, and response to PAP, and should be part of the discussion between the health care provider and patient (Kent, 2021).

OSA is a chronic disease that rarely resolves except with substantial weight loss or successful corrective surgery. As with other chronic diseases, periodic follow-up by a qualified clinician (eg, physician or advanced practice provider) is necessary to confirm adequate treatment, assess symptom resolution, and promote continued adherence to treatment. Initial treatment of
OSA requires close monitoring and early identification of difficulties with PAP use, as adherence over the first few days to weeks has been shown to predict long-term adherence. Objective monitoring of PAP therapy should be performed to complement patient reporting of difficulties with PAP use, as patients often overestimate their use of PAP treatment. (Patil, et al, 2019)

PAP therapy remains the gold standard for treating OSA. Alternative approaches may be appropriate for patients unable to tolerate PAP. Untreated OSA can cause daytime sleepiness, reduced productivity, increased accident risk, and worsening cardiovascular conditions such as hypertension, atrial fibrillation, and stroke (Pavwoski, et al, 2017).