2026 COLLECTION TYPE:
MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)
MEASURE TYPE: Process – High Priority
Description:
Percentage of patients, regardless of age, with a diagnosis of Human Immunodeficiency Virus (HIV) before or during the first 240 days of the performance period who had at least two eligible encounters or at least one eligible encounter and one HIV viral load test that were at least 90 days apart within the performance period.
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 the primary management of patients with HIV. 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 for 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:
Patients, regardless of age, with a diagnosis of HIV before or during the first 240 days of the performance period who had at least one eligible encounter during the first 240 days of the performance period.
DENOMINATOR NOTE:
Only patients with an eligible encounter in the first 240 days are included in this measure to allow for sufficient time to complete a second eligible encounter or viral load laboratory at least 90 days after the initial encounter during the performance period.
*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 (eligible Cases):
Patients, regardless of age
And
Diagnosis of HIV prior to the performance period or during the first 90 days of the performance period (ICD-10-CM): B20, Z21, B97.35, O98.711, O98.712, O98.713, O98.719, O98.72, O98.73
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, 98966, 98967, 98968, , 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, *, 99242*, 99244*, 99245*, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381*, 99382*, 99383*, 99384*,99385*, 99386, 99387, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, 99429*, G0402, G0438, G0439
Numerator:
Number of patients who had at least one eligible encounter and one HIV viral load test at least 90 days apart during the performance period, or who had at least two eligible encounters at least 90 days apart during the performance period
NUMERATOR NOTE:
A patient would be included in the measure numerator if they have either 1) two eligible encounters at least 90 days apart, or 2) one eligible encounter and one viral load test at least 90 days apart from each other. The encounter or encounters that cause a patient to be included in the numerator do not need to include the encounter that caused the patient to be included in the denominator.
Numerator Options:
Performance Met: Patient had two eligible encounters at least 90 days apart or one eligible encounter and one HIV viral load test at least 90 days apart (G9247)
Or
Performance Not Met: Patient did not have two eligible encounters at least 90 days apart or one eligible encounter and one HIV viral load test at least 90 days apart (G9246)
Rationale:
“Retention in care should be routinely monitored. There are various ways to measure retention, including measures based on attended visits over a defined period of time (constancy measures), and measures based on missed visits. Both approaches are valid and independently predict survival. Missed visits and a prolonged time since last visit are relatively easy to measure and should trigger efforts to retain or re-engage a person in care. Constancy measures (e.g., at least two visits that are at least 90 days apart over 1 year, or at least one visit every 6 months over the last 2 years), can be used as clinic quality assurance measures.” (DHHS, Adult, 2025)
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