2020 MIPS Measure #066: Appropriate Testing for Children with Pharyngitis

Measure Description

Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode

Instructions

This measure is to be submitted once for each occurrence of pharyngitis during the performance period. Claims data will be analyzed to determine unique occurrences. This measure is intended to reflect the quality of services provided for the primary management of patients with pharyngitis who were dispensed an antibiotic. 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 3 - 18 years of age who had an outpatient or emergency department (ED) visit with a diagnosis of pharyngitis during the measurement period and an antibiotic ordered on or three days after the visit

Denominator Instruction:

To determine eligibility, look for any of the listed antibiotic drugs below in the 30 days prior to the visit with the pharyngitis 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 to 18 years on date of encounter

AND

Diagnosis for pharyngitis (ICD-10-CM): J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91

AND

Patient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99241*, 99242*, 99243*,99244*, 99245*, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99401*, 99402*,99403*, 99404*, 99411*, 99412*, 99429*, 99455, 99456, 99281, 99282, 99283, 99284, 99285, 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*

AND

Prescribed or dispensed antibiotic: G8711

AND NOT

DENOMINATOR EXCLUSIONS:

Patients who use hospice services any time during the measurement period: G9702

OR

Children who are taking antibiotics in the 30 days prior to the diagnosis of pharyngitis: G9703

OR

Children with a competing diagnosis for Upper Respiratory Infection within three days of diagnosis of pharyngitis (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): G2097

Table 1 - Antibiotic Medications

Numerator

Children with a group A streptococcus test in the 7-day period from 3 days prior through 3 days after the diagnosis of pharyngitis

Numerator Instruction:

A higher score indicates appropriate treatment of children with pharyngitis (e.g., the proportion for whom antibiotics were prescribed with an accompanying step test).

Numerator Options:

Performance Met: Group A Strep Test Performed (3210F)

OR

Performance Not Met: Group A Strep Test not Performed, reason not otherwise specified (3210F with 8P)

Rationale

Group A streptococcal bacterial infections and other infections that cause pharyngitis (which are most often viral) often produce the same signs and symptoms (Shulman et al., 2012). The American Academy of Pediatrics, the Centers for Disease Control and Prevention, and the Infectious Diseases Society of America all recommend a diagnostic test for Strep A to improve diagnostic accuracy and avoid unnecessary antibiotic treatment (Linder et al. 2005).

Estimated economic costs of pediatric streptococcal pharyngitis in the United States range from $224 million to $539 million per year, including indirect costs related to parental work losses. At a higher level, the economic cost of antibiotic resistance vary but have extended as high as $20 billion in excess direct healthcare costs, with additional costs to society for lost productivity as high as $35 billion a year (2008 dollars) (Roberts et al. 2009).

Clinical Recommendation Statements

Infectious Disease Society of America (2012)

The Infectious Diseases Society of America (IDSA) “recommends swabbing the throat and testing for GAS pharyngitis by rapid antigen detection test (RADT) and/or culture because the clinical features alone do not reliably discriminate between GAS and viral pharyngitis except when overt viral features like rhinorrhea, cough, oral ulcers, and/or hoarseness are present