2026 #331 MIPS Measure Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)

‌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 aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms.

‌INSTRUCTIONS:

Reporting Frequency:

This measure is to be submitted once for each occurrence of acute viral sinusitis (AVS) 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 acute viral sinusitis. Each unique occurrence starts with the onset of AVS symptoms and concludes with the resolution of AVS symptoms. This measure may be submitted based on the actions of the submitting Merit-based Incentive Payment System (MIPS) eligible clinician who performs the quality action, as defined by the numerator, based on the services provided within 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, each unique occurrence starts with the onset of AVS symptoms and concludes with the resolution of AVS symptoms or after 90 days if a resolution of AVS symptoms is not documented. A new occurrence of AVS cannot start until the previous occurrence during the performance period has concluded. If multiple denominator eligible encounters are documented within an identified occurrence, MIPS eligible clinicians should submit the most recent encounter associated within that occurrence.

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.

‌DENOMINATOR:

All patients aged 18 years and older with a diagnosis of acute viral sinusitis.

Definition:

Acute Sinusitis/Rhinosinusitis – Up to 4 weeks of purulent nasal drainage (anterior, posterior, or both) accompanied by nasal obstruction, facial pain-pressure-fullness, or both:

• Purulent nasal discharge is cloudy or colored, in contrast to the clear secretions that typically accompany viral upper respiratory infection and may be reported by the patient or observed on physical examination. Nasal obstruction may be reported by the patient as nasal obstruction, congestion, blockage, or stuffiness, or may be diagnosed by physical examination
• Facial pain-pressure-fullness may involve the anterior face, periorbital region, or manifest with headache that is localized or diffuse

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter

AND

Diagnosis for acute sinusitis on date of encounter (ICD-10-CM): J01.00, J01.01, J01.10, J01.11, J01.20, J01.21, J01.30, J01.31, J01.40, J01.41, J01.80, J01.81, J01.90, J01.91

AND

Patient encounter during performance period (CPT): 98002, 98003, 98006, 98007, 98010, 98011, 98014, 98015, 98016, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99424, 99491

‌NUMERATOR:

Patients prescribed any antibiotic within 10 days after onset of symptoms.

NUMERATOR NOTE:

In the instance that the diagnosis of sinusitis is bacterial and not viral, the Denominator Exception would be applicable. This could be supported by the documentation of:

1. Persistent symptoms of acute rhinosinusitis—such as purulent nasal discharge accompanied by nasal obstruction, facial pain, pressure, or fullness—that continue without improvement for at least 10 days beyond the onset of initial upper respiratory symptoms; or
2. Worsening symptoms (e.g., new onset of fever, increased nasal discharge, or facial pain) occurring within 10 days after an initial period of improvement—a pattern known as “double worsening.”

Numerator Options:

Performance Not Met: Antibiotic regimen not prescribed within 10 days after onset of symptoms (G9287)

OR

Denominator Exception: Antibiotic regimen prescribed within 10 days after onset of symptoms for documented medical reason (G9505)

OR

Performance Met: Antibiotic regimen prescribed within 10 days after onset of symptoms (G9286)

RATIONALE:

Antibiotic treatment for sinusitis is indicated for some patients, but overtreatment of acute sinusitis with antibiotics is common and often not indicated. Further, treatment with antibiotics may increase patient harm and can lead to antibiotic resistance.
A 2018 Cochrane systematic review update was undertaken to assess the effects of antibiotics versus placebo or no treatment in adults with acute rhinosinusitis in ambulatory care settings.1 Acute rhinosinusitis is a common condition that involves blockage of the nose passage and mucus in the sinuses. It is often caused by a viral upper respiratory tract infection of which only 0.5% to 2% of cases are estimated to be complicated by a bacterial rhinosinusitis. Nevertheless, antibiotics (used to treat bacterial infections) are often prescribed. Unnecessary prescribing contributes to antimicrobial resistance in the community. The authors concluded that given the lack of clear benefit in terms of rapid recovery and the increase in side effects in participants treated with antibiotics, antibiotics are not recommended as first line treatment in adults with clinically diagnosed acute rhinosinusitis.