2020 MIPS Measure #065: Appropriate Treatment for Children with Upper Respiratory Infection (URI)

Measure Description

Percentage of children 3 months - 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode

Instructions

This measure is to be submitted once for each occurrence of upper respiratory infection during the performance period. Claims data will be analyzed to determine unique occurrences. 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.

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

Children age 3 months to 18 years of age who had an outpatient or emergency department (ED) visit with a diagnosis of upper respiratory infection (URI) during the measurement period

Denominator Instructions:

This is an episode of care measure that examines all eligible episodes for the patient during the measurement period. If the patient has more than one episode, include all episodes in the measure.

To determine eligibility, look for any of the listed antibiotic drugs below in the 30 days prior to the visit with the URI diagnosis. As long as there are no prescriptions for the listed antibiotics during this time period, the patient is eligible for denominator inclusion.

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 3 months to 18 years on date of encounter

AND

Diagnosis for URI (ICD-10-CM): J00, J06.0, J06.9

AND

Patient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99218, 99219, 99220, 99281, 99282, 99283, 99284, 99285, 99381*, 99382*, 99383*, 99384*, 99391*, 99392*, 99393*, 99394*

AND NOT

DENOMINATOR EXCLUSIONS:

Patient prescribed or dispensed antibiotic for documented medical reason(s) within three days after the initial diagnosis of URI (e.g., intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, acute sinusitis, acute pharyngitis, acute tonsillitis, chronic sinusitis, infection of the pharynx/larynx/tonsils/adenoids, prostatitis, cellulitis, mastoiditis, or bone infections, acute lymphadenitis, impetigo, skin staph infections, pneumonia/gonococcal infections, venereal disease (syphilis, chlamydia, inflammatory diseases [female reproductive organs]), infections of the kidney, cystitis or UTI, and acne): G8709

OR

Children who are taking antibiotics in the 30 days prior to the date of the encounter during which the diagnosis was established: G9701

OR

Patients who use hospice services any time during the measurement period: G9700

Numerator

Children without a prescription for antibiotic medication on or 3 days after the outpatient or ED visit for an upper respiratory infection

Numerator Instructions:

For performance, the measure will be calculated as the number of patient’s encounter(s) where antibiotics were neither prescribed nor dispensed on or within three days of the episode for URI over the total number of encounters in the denominator (patients aged 3 months to 18 years with an outpatient or ED visit for URI. A higher score indicates appropriate treatment of patients with URI (e.g., the proportion for whom antibiotics were not prescribed or dispensed following the episode).

Table 1 - Antibiotic Medications

Numerator Options:

Performance Met: Patient not prescribed or dispensed antibiotic (G8708)

OR

Performance Not Met: Patient prescribed or dispensed antibiotic (G8710)

Rationale

Most upper respiratory infections (URI), also known as the common cold, are caused by viruses that require no antibiotic treatment. Too often, antibiotics are prescribed inappropriately, which can lead to antibiotic resistance (when antibiotics can no longer cure bacterial infections). In the United States, at least 2 million antibiotic-resistant illnesses and 23,000 deaths occur each year, at a cost to the U.S. economy of at least $30 billion.

Clinical Recommendation Statements

American Family Physician (Fashner, Ericson, and Werner, Khilberg 2012)

• Antibiotics should not be used for the treatment of cold symptoms in children or adults. (A)
• Nonsteroidal anti-inflammatory drugs reduce pain secondary to upper respiratory tract infection in adults. (A)
• Decongestants, antihistamine/decongestant combinations, and intranasal ipratropium (Atrovent) may improve cold symptoms in adults. (B)