2026 #398 MIPS Measure Optimal Asthma Control

‌2026 COLLECTION TYPE:

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

‌MEASURE TYPE:

Outcome – High Priority

‌DESCRIPTION:

Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation.

‌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 asthma. 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 two strata defined by two submission criteria. This measure produces seven performance rates.

There are 2 Submission Criteria for this measure:

1. Patients aged 5-17 years with well-controlled asthma, without elevated risk of exacerbation

OR

1. Patients aged 18-50 years with well-controlled asthma, without elevated risk of exacerbation

This measure will be calculated with 7 performance rates:

1. Overall Percentage for patients (aged 5-50 years) with well-controlled asthma, without elevated risk of exacerbation
2. Percentage of pediatric patients (aged 5-17 years) with well-controlled asthma, without elevated risk of exacerbation
3. Percentage of adult patients (aged 18-50 years) with well-controlled asthma, without elevated risk of exacerbation
4. Asthma well-controlled (submit the most recent specified asthma control tool result) for patients 5 to 17 with Asthma
5. Asthma well-controlled (submit the most recent specified asthma control tool result) for patients 18 to 50 with Asthma
6. Patient not at elevated risk of exacerbation for patients 5 to 17 with Asthma
7. Patient not at elevated risk of exacerbation for patients 18 to 50 with Asthma

All performance rates must be submitted for this measure. For accountability reporting in the CMS MIPS program, Performance Rate 1 is used for performance.

‌Implementation Considerations:

For the purposes of MIPS implementation, this patient-intermediate measure is submitted a minimum of once per patient for the performance period. The most recent numerator option/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.

SUBMISSION CRITERIA 1: PATIENTS AGED 5-17 YEARS WITH WELL CONTROLLED ASTHMA, WITHOUT ELEVATED RISK OF EXACERBATION

‌DENOMINATOR (CRITERIA 1):

Patients ages 5 to 17 with asthma.

‌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.

Visits to a primary care setting, regardless of the reason for the visit or the scheduling status of the visit (e.g., walk-in) are to be included. In a multi-specialty clinic setting, patients who have visits from both the primary care setting and the urgent care setting during the performance period are to be included. M1021 may be used if the patient is only evaluated at an urgent care visit and is not considered an established patient to allow for care coordination or follow up.

‌Denominator Criteria (Eligible Cases):

Patients aged 5-17 years

AND

Diagnosis for asthma (ICD-10-CM): J45.20, J45.21, J45.22, J45.30, J45.31, J45.32, J45.40, J45.41, J45.42, J45.50, J45.51, J45.52, J45.901, J45.902, J45.909, J45.990, J45.991, J45.998

AND

Patient had a diagnosis of asthma with any contact during the current or prior performance period OR had asthma present on an active problem list any time during the performance period: M1457

AND

Established patient office or telehealth visit during the performance period (CPT): 98012, 98013, 98014, 98015, 98016, 99211, 99212, 99213, 99214, 99215, 99392, 99393*, 99394*, 99395, 99396, 99421, 99422, 99423 AND NOT

DENOMINATOR EXCLUSIONS:

Diagnosis for chronic obstructive pulmonary disease, emphysema, cystic fibrosis, or acute respiratory failure: M1460

OR

Patient died prior to the end of the performance period: M1458

OR

Patient was in hospice or receiving palliative care services at any time during the performance period: M1459

OR

Patient had only urgent care visits during the performance period: M1021

‌Reference Coding:

Denominator Exclusion for chronic obstructive pulmonary disease, emphysema, cystic fibrosis, or acute respiratory failure [M1460] may be defined by the following coding, however, other codes/code languages that meet the intent of this component may also be used:

E84.0, E84.11, E84.19, E84.8, E84.9, J43.0, J43.1, J43.2, J43.8, J43.9, J44.0, J44.1, J44.81, J44.89, J44.9, J68.4, J96.00, J96.01, J96.02, J96.20, J96.21, J96.22, J98.2, J98.3

‌NUMERATOR (ALL OR NOTHING):

The number of asthma patients who meet ALL of the following targets.

‌Numerator Options:

Each component should be submitted in order to determine the data completeness and performance rate for the overall percentage of patients that meet ALL targets represented as the numerator.

‌COMPONENT 1:

Asthma well-controlled (submit the most recent asthma control tool result available during the measurement period) Asthma Control TestTM (ACT) result of 20 or above – ages 12 and older

Childhood Asthma Control TestTM (C-ACT) result of 20 or above – ages 11 and younger Asthma Control Questionnaire (ACQ) result of 0.75 or lower – ages 17 and older

Asthma Therapy Assessment Questionnaire (ATAQ) result of 0 – Pediatric (ages 5 – 17) or Adult (ages 18 and older)

‌Component Options:‌

Performance Met: Asthma well-controlled based on the ACT, C-ACT, ACQ, or ATAQ score and results documented (G9432)

‌OR

Performance Not Met: Asthma not well-controlled based on the ACT, C-ACT, ACQ, or ATAQ score, OR specified asthma control tool not used, reason not given (G9434)

AND

‌COMPONENT 2:

Patient not at elevated risk of exacerbation

‌NUMERATOR NOTE:

To meet performance for this component, documentation of the sum of the patient’s submitted values for the following questions must be less than two:

• Number of emergency department visits not resulting in a hospitalization due to asthma in last 12 months
• Number of inpatient hospitalizations requiring an overnight stay due to asthma in last 12 months.

‌Component Options:

‌Performance Met: Total number of emergency department visits and inpatient hospitalizations less than two in the past 12 months (G9521)

OR

‌Performance Not Met: Total number of emergency department visits and inpatient hospitalizations equal to or greater than two in the past 12 months OR patient not screened, reason not given (G9522)

OR

SUBMISSION CRITERIA 2: PATIENTS AGED 18-50 YEARS WITH WELL CONTROLLED ASTHMA, WITHOUT ELEVATED RISK OF EXACERBATION

‌DENOMINATOR (CRITERIA 2):

Patients ages 18 to 50 with asthma

‌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.

Visits to a primary care setting, regardless of the reason for the visit or the scheduling status of the visit (e.g., walk-in) are to be included. In a multi-specialty clinic setting, patients who have visits from both the primary care setting and the urgent care setting during the performance period are to be included. M1021 may be used if the patient is only evaluated at an urgent care visit and is not considered an established patient to allow for care coordination or follow up.

‌Denominator Criteria (Eligible Cases):

Patients aged 18-50 years

AND

Diagnosis for asthma (ICD-10-CM): J45.20, J45.21, J45.22, J45.30, J45.31, J45.32, J45.40, J45.41, J45.42, J45.50, J45.51, J45.52, J45.901, J45.902, J45.909, J45.990, J45.991, J45.998

AND

Patient had a diagnosis of asthma with any contact during the current or prior performance period OR had asthma present on an active problem list any time during the performance period: M1457

AND

Established patient office or telehealth visit during the performance period (CPT): 98012, 98013, 98014, 98015, 98016, 99211, 99212, 99213, 99214, 99215, 99392, 99393, 99394, 99395*, 99396*, 99421, 99422, 99423

AND NOT

DENOMINATOR EXCLUSIONS:

Diagnosis for chronic obstructive pulmonary disease, emphysema, cystic fibrosis, or acute respiratory failure: M1460

OR

Patient died prior to the end of the performance period: M1458

OR

Patient was in hospice or receiving palliative care services at any time during the performance period: M1459

OR

Patient had only urgent care visits during the performance period: M1021

‌Reference Coding:

Denominator Exclusion for chronic obstructive pulmonary disease, emphysema, cystic fibrosis, or acute respiratory failure [M1460] may be defined by the following coding, however, other codes/code languages that meet the intent of this component may also be used:

E84.0, E84.11, E84.19, E84.8, E84.9, J43.0, J43.1, J43.2, J43.8, J43.9, J44.0, J44.1, J44.81, J44.89, J44.9, J68.4, J96.00, J96.01, J96.02, J96.20, J96.21, J96.22, J98.2, J98.3

‌NUMERATOR (ALL OR NOTHING):

The number of asthma patients who meet ALL of the following targets

‌Numerator Options:

Each component should be submitted in order to determine the data completeness and performance rate for the overall percentage of patients that meet ALL targets represented as the numerator.

‌COMPONENT 1:

Asthma well-controlled (submit the most recent asthma control tool result available during the measurement period) Asthma Control TestTM (ACT) result of 20 or above – ages 12 and older

Asthma Control Questionnaire (ACQ) result of 0.75 or lower – ages 17 and older

Asthma Therapy Assessment Questionnaire (ATAQ) result of 0 – Pediatric (ages 5 – 17) or Adult (ages 18 and older)

‌Component Options:‌

Performance Met: Asthma well-controlled based on the ACT, C-ACT, ACQ, or ATAQ score and results documented (G9432)

OR

‌Performance Not Met: Asthma not well-controlled based on the ACT, C-ACT, ACQ, or ATAQ score, OR specified asthma control tool not used, reason not given (G9434)

AND

‌COMPONENT 2:

Patient not at elevated risk of exacerbation.

‌NUMERATOR NOTE:

To meet performance for this component, documentation of the sum of the patient’s submitted values for the following questions must be less than two:

• Number of emergency department visits not resulting in a hospitalization due to asthma in last 12 months
• Number of inpatient hospitalizations requiring an overnight stay due to asthma in last 12 months

‌Component Options:‌

Performance Met: Total number of emergency department visits and inpatient hospitalizations less than two in the past 12 months (G9521)

‌OR

Performance Not Met: Total number of emergency department visits and inpatient hospitalizations equal to or greater than two in the past 12 months OR patient not screened, reason not given (G9522)

RATIONALE:

Roughly 7% of adults and children in Minnesota are currently living with asthma. Asthma is a chronic disease associated with familial, infectious, allergenic, socioeconomic, psychosocial, and environmental factors. It is not curable but is treatable. Despite improvements in diagnosis and management, and an increased understanding of the epidemiology, immunology, and biology of the disease, asthma prevalence has progressively increased over the past 15 years.