2026 #464 MIPS Measure Otitis Media with Effusion: Systemic Antimicrobials – Avoidance of Inappropriate Use

2026 COLLECTION TYPE:

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

‌MEASURE TYPE: ‌Process – High Priority

Description:

Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials.

‌Instructions:

Reporting Frequency:
This measure is to be submitted once for each occurrence of otitis media with effusion (OME) in children seenduring the performance period.

Intent and Clinician Applicability:
This measure is intended to reflect the quality of services provided for patients with a diagnosis of OME. 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, each unique occurrence starts with the onset of OME symptoms and concludes with the resolution of OME or after 90 days if a resolution of OME symptoms is not documented. A new occurrence of OME cannot start until the previous occurrence during the performance period has concluded. If multiple denominator eligible encounters are documented within an identified occurrence, Merit-based Incentive Payment System (MIPS) eligible clinicians should submit the most recent encounter associated within that occurrence.

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 2 months through 12 years with a diagnosis of OME

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):

Patients aged 2 months through 12 years on the date of the encounter

AND

Diagnosis for OME (ICD-10-CM): H65.90, H65.91, H65.92, H65.93, H65.111, H65.112, H65.113, H65.114, H65.115, H65.116, H65.117, H65.119, H65.191, H65.192, H65.193, H65.194, H65.195, H65.196, H65.197, H65.199, H65.411, H65.412, H65.413, H65.419, H65.491, H65.492, H65.493, H65.499

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, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99381*, 99382*, 99383*, 99384*, 99391*, 99392*, 99393*, 99394*

Numerator:

Patients who were not prescribed systemic antimicrobials

Numerator Instructions:
For performance, the measure will be calculated as the number of patients for whom systemic antimicrobials were neither prescribed nor recommended over the number of patients in the denominator (patients aged 2 months through 12 years with a diagnosis of OME). A higher score indicates appropriate treatment of patients with OME (e.g., the proportion for whom systemic antimicrobials were not prescribed).

Numerator Options:

Performance Met: Systemic antimicrobials not prescribed (G9959)

OR

Denominator Exception: Documentation of medical reason(s) for prescribing systemic antimicrobials (G9960)

OR

Performance Not Met: Systemic antimicrobials prescribed (G9961)

RATIONALE:

OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic antimicrobials have no proven long-term effectiveness and have potential adverse effects. The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving quality of life (QOL) and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME.