2025 MIPS Measure HIV Annual Retention in Care

2025 COLLECTION TYPE:

‌MIPS CLINICAL QUALITY MEASURES (CQMS)

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:

This measure is to be submitted a minimum of once per performance period for patients with HIV seen during the performance period. 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 described in the measure based on the services provided and the measure-specific denominator coding.

‌NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, 95, POS 02, POS 10) are allowable. Please note that effective January 1, 2025, while a measure may be denoted as telehealth eligible, specific denominator codes within the encounter may no longer be eligible due to changes outlined in the CY 2024 PFS Final Rule List of Medicare Telehealth Services.

Measure Submission Type:

‌Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. 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 (ICD-10-CM): B20, Z21

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, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381*, 99382*, 99383*, 99384*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*

‌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)

‌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)