2026 #332 MIPS Measure Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)

‌2026 COLLECTION TYPE:

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

‌MEASURE TYPE:

Process – High Priority

‌DESCRIPTION:

Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis.

‌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 a diagnosis of acute bacterial sinusitis. 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, 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 acute bacterial sinusitis who are prescribed an antibiotic.

Definition:

Acute Bacterial Rhinosinusitis (ABRS) – Acute rhinosinusitis that is caused by, or is presumed to be caused by, bacterial infection. A clinician should diagnose ABRS when: (a) symptoms or signs of acute rhinosinusitis are present 10 days or more beyond the onset of upper respiratory symptoms, or (b) symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening).

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

Diagnosis for bacterial and infectious agents on date of encounter (ICD-10-CM): B95.0, B95.1, B95.2, B95.3, B95.4, B95.5, B95.61, B95.62, B95.7, B95.8, B96.0, B96.1, B96.20, B96.21, B96.22, B96.23, B96.29, B96.3, B96.4, B96.5, B96.6, B96.7, B96.81, B96.82, B96.83, B96.89

OR

Sinusitis caused by, or presumed to be caused by, bacterial infection: G9364

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

AND

Antibiotic regimen prescribed: G9498

‌NUMERATOR:

Patients who were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis.

Numerator Options:

Performance Met: Amoxicillin, with or without clavulanate, prescribed asa first line antibiotic at the time of diagnosis (G9315)

OR

Denominator Exception: Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time of diagnosis for documented reason (G9313)

OR

Performance Not Met: Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time of diagnosis, reason not given (G9314)

RATIONALE:

The rationale for antibiotic therapy of ABRS is to eradicate bacterial infection from the sinuses, hasten resolution of symptoms, and enhance disease-specific quality of life. Antibiotic therapy should be efficacious, cost-effective, and result in minimal side effects.