2026 #387 MIPS Measure Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users

‌2026 COLLECTION TYPE:

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

‌MEASURE TYPE:

Process

‌DESCRIPTION:

Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting 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 Clinical Applicability:

This measure is intended to reflect the quality of services provided for patients regardless of age, who are active injection drug users. 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:

All patients, regardless of age, who are seen twice for any visit or who had at least one preventive visit within the 12- month reporting period who are active injection drug users.

‌Definition:

Active injection drug users – Those who have injected any drug(s) within the 12-month reporting period.

‌DENOMINATOR NOTE:

*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):

All patients regardless of age

AND

At least one preventive encounter during the performance period (CPT or HCPCS): 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, G0438, G0439

OR

At least two patient encounters 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, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350

AND

Documentation of active injection drug use: G9518

AND NOT

DENOMINATOR EXCLUSION:

Diagnosis for Chronic Hepatitis C during performance period (ICD-10-CM): B18.2

‌NUMERATOR:

Patients who received screening for HCV infection within the 12-month reporting period.

‌Definition:

Screening for HCV infection – includes HCV antibody test or HCV RNA test.

‌NUMERATOR NOTE:

Denominator Exception(s) are determined on the date of the most recent denominator eligible encounter.

‌Numerator Options:‌

Performance Met: Patient received screening for HCV infection within the 12-month reporting period (G9383)

‌OR

Denominator Exception: Documentation of medical reason(s) for not receiving annual screening for HCV infection (e.g., decompensated cirrhosis indicating advanced disease [i.e., ascites, esophageal variceal bleeding, hepatic encephalopathy], hepatocellular carcinoma, waitlist for organ transplant, limited life expectancy, other medical reasons) (G9384)

OR

‌Denominator Exception: Documentation of patient reason(s) for not receiving annual screening for HCV infection (e.g., patient declined, other patient reasons) (G9385)

‌OR

Performance Not Met: Screening for HCV infection not received within the 12- month reporting period, reason not given (G9386)

RATIONALE:

Of the estimated 3.5 million people living in the United States with the hepatitis C virus infection (HCV), only 50% have been tested for HCV and are aware of their status. Reported cases of HCV have increased (approximately 20% per year) between 2010-2016, which is only partially due to improved case detection and more likely due to rising rates of injection drug use. Additionally, only one third have been referred for HCV care and only 5.6% receive recommended treatment. Studies indicate that even among high-risk patients for whom screening is recommended, only 49-75% are aware of their infection status. In a recent analysis of data from a national health survey, 67.9 % of persons ever infected with HCV reported an exposure risk, (e.g., injection drug use, having sexual contact with suspected/confirmed hepatitis C patient), 2 weeks to 6 months prior to symptom onset, and the remaining 32.1% reported no known exposure risk. Data from the CDC shows that of the 2016 case reports that had information about drug use, 68.6% reported the use of injection drugs. According to one study, 72% of persons with a history of injection-drug use who are infected with HCV remain unaware of their infection status. Current risk-based testing strategies have had limited success, as evidenced by the substantial number of HCV-infected persons who remain unaware of their infection. As a result, many do not receive needed care (e.g., education, counseling, and medical monitoring), and are not evaluated for treatment. HCV causes acute infection, which can be characterized by mild to severe illness but is usually asymptomatic. In approximately 75%-85% of persons, HCV persists as a chronic infection, placing infected persons at risk for liver cirrhosis, hepatocellular carcinoma (HCC), and extrahepatic complications that develop over the decades following onset of infection.

Since 1998, routine HCV testing has been recommended by CDC for persons most likely to be infected with HCV. These recommendations were made on the basis of a known epidemiologic association between a risk factor and acquiring HCV infection, including injection drug use. It is estimated that most new cases of HCV infections are among young persons who are white, live in non-urban areas and have a history of previously reported injection drug use. An epidemic has arisen that is a national priority for federal and state public health agencies. HCV testing is the first step toward improving health outcomes for persons who report injection drug use and are infected with HCV.