Percentage of patients, regardless of age, with psoriasis, psoriatic arthritis and rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test
This measure is to be submitted a minimum of once per performance period for patients with psoriasis and/or psoriatic arthritis and/or rheumatoid arthritis seen during the performance period. 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.
All patients, regardless of age, with a diagnosis of psoriasis and/or psoriatic arthritis and/or rheumatoid arthritis who are on a biologic immune response modifier
Biologic Immune Response Modifier –
1. TNF-alpha inhibitors, to include, but not limited toInfliximab (Remicade), Adalimumab (Humira), Etanercept (Enbrel), or Golimumab (Simponi), Certolizumab (Cimzia).
2. Inhibitors of IL-12 and/or IL-23 or their receptors to include but not limited to Ustekinumab (Stelara).
3. B7 inhibitors, to include but not limited to Abatacept (Orencia).
4. Inhibitors of IL-17 family members or their receptors.
DENOMINATOR NOTE: A patient would be considered denominator eligible for Measure #337 for submission purposes, if the patient meets the denominator criteria with diagnosis of psoriasis or psoriatic arthritis or rheumatoid arthritis AND is on a biologic immune response modifier PRESCRIBED BY THE PROVIDER BEING EVALUATED FOR THE MEASURE.
*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.
Examples of Applicable Medications
Mechanism of Action/ Type of Biologic
Blocks T cell activation
CD 20 directed antibody
Interleukin (IL)-1 inhibitors
IL-12 and IL-23 inhibitors
Selective (IL)-23p19 inhibitor
Simponi and Simponi Aria
Denominator Criteria (Eligible Cases):
All patients, regardless of age
Diagnosis for psoriasis (ICD-10-CM): L40.0, L40.1, L40.2, L40.3, L40.4, L40.8, L40.9
Diagnosis for psoriatic arthritis (ICD-10-CM): L40.50, L40.51, L40.52, L40.53, L40.54, L40.59
Diagnosis for rheumatoid arthritis (ICD-10-CM): M05.10, M05.111, M05.112, M05.119, M05.121, M05.122, M05.129, M05.131, M05.132, M05.139, M05.141, M05.142, M05.149, M05.151, M05.152, M05.159, M05.161, M05.162, M05.169, M05.171, M05.172, M05.179, M05.19, M05.20, M05.211, M05.212, M05.219, M05.221, M05.222, M05.229, M05.231, M05.232, M05.239, M05.241, M05.242, M05.249, M05.251, M05.252, M05.259, M05.261, M05.262, M05.269, M05.271, M05.272, M05.279, M05.29, M05.30, M05.311, M05.312, M05.319, M05.321, M05.322, M05.329, M05.331, M05.332, M05.339, M05.341, M05.342, M05.349, M05.351, M05.352, M05.359, M05.361, M05.362, M05.369, M05.371, M05.372, M05.379, M05.39, M05.40, M05.411, M05.412, M05.419, M05.421, M05.422, M05.429, M05.431, M05.432, M05.439, M05.441, M05.442, M05.449, M05.451, M05.452, M05.459, M05.461, M05.462, M05.469, M05.471, M05.472, M05.479, M05.49, M05.50, M05.511, M05.512, M05.519, M05.521, M05.522, M05.529, M05.531, M05.532, M05.539, M05.541, M05.542, M05.549, M05.551, M05.552, M05.559, M05.561, M05.562, M05.569, M05.571, M05.572, M05.579, M05.59, M05.60, M05.611, M05.612, M05.619, M05.621, M05.622, M05.629, M05.631, M05.632, M05.639, M05.641, M05.642, M05.649, M05.651, M05.652, M05.659, M05.661, M05.662, M05.669, M05.671, M05.672, M05.679, M05.69, M05.70, M05.711, M05.712, M05.719, M05.721, M05.722, M05.729, M05.731, M05.732, M05.739, M05.741, M05.742, M05.749, M05.751, M05.752, M05.759, M05.761, M05.762, M05.769, M05.771, M05.772, M05.779, M05.79, M05.80, M05.811, M05.812, M05.819, M05.821, M05.822, M05.829, M05.831, M05.832, M05.839, M05.841, M05.842, M05.849, M05.851, M05.852, M05.859, M05.861, M05.862, M05.869, M05.871, M05.872, M05.879, M05.89, M05.9, M06.00, M06.011, M06.012, M06.019, M06.021, M06.022, M06.029, M06.031, M06.032, M06.039, M06.041, M06.042, M06.049, M06.051, M06.052, M06.059, M06.061, M06.062, M06.069, M06.071, M06.072, M06.079, M06.08, M06.09, M06.1, M06.20, M06.211, M06.212, M06.219, M06.221, M06.222, M06.229, M06.231, M06.232, M06.239, M06.241, M06.242, M06.249, M06.251, M06.252, M06.259, M06.261, M06.262, M06.269, M06.271, M06.272, M06.279, M06.28, M06.29, M06.30, M06.311, M06.312, M06.319, M06.321, M06.322, M06.329, M06.331, M06.332, M06.339, M06.341, M06.342, M06.349, M06.351, M06.352, M06.359, M06.361, M06.362, M06.369, M06.371, M06.372, M06.379, M06.38, M06.39, M06.80, M06.811, M06.812, M06.819, M06.821, M06.822, M06.829, M06.831, M06.832, M06.839, M06.841, M06.842, M06.849, M06.851, M06.852, M06.859, M06.861, M06.862, M06.869, M06.871, M06.872, M06.879, M06.88, M06.89, M06.9
Patient encounter during performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, G0402
Telehealth Modifier: GQ, GT, 95, POS 02
Biologic immune response modifier prescribed: G9506
Patients who have a documented negative TB screening or have documentation of the management of a positive TB screening test with no evidence of active tuberculosis, confirmed through use of radiographic imaging (i.e., chest x-ray, CT) prior to treatment with a biologic immune response modifier
Documentation – To satisfy this measure, documentation will incorporate the following:
• Initials of the clinician that prescribed the biologic
• Initials of clinician that administered the TB test
• Initials of the clinician that performed the skin test evaluating the results note in the medical record that results are negative OR that results are positive and is confirmed via results from radiographic imaging (chest x-ray, CT)
If TB test is administered by a provider other than the biologic prescriber, confirmation of the above mentioned must be obtained via letter or other written means from the administering provider.
NUMERATOR NOTE: For Denominator Exception(s): patients are ineligible for this measure if at the time of follow-up there are patient reason(s) for not documenting TB test results (e.g. patient did not return for Mantoux (PPD) skin test evaluation).
Performance Met: Documentation of negative or managed positive TB screen with further evidence that TB is not active prior to treatment with a biologic immune response modifier (G9359)
Denominator Exception: Documentation of patient reasons(s) for not having records of negative or managed positive TB screen (e.g., patient does not return for Mantoux (PPD) skin test evaluation) (G9932)
Performance Not Met: No documentation of negative or managed positive TB screen (G9360)
Pretreatment test for latent TB is essential for appropriate patient care and safety. Prior to the initiation of a biologic immune response modifier, it’s important to know the TB status as to prevent tuberculosis reactivation or any type of harm to the patient.
Clinical Recommendation Statements
When planning to initiate treatment of a patient with psoriasis with a biologic it is important to obtain an age appropriate history and physical examination along with an updated medication list. In addition, it is also important to obtain a reliable set of baseline laboratory studies that will allow the clinician to detect and be aware of any underlying conditions or risk factors. This is particularly important because after patients have been initiated on a biologic treatment, they are likely to be treated with other biologics or systemic therapies and it may be useful to have reliable baseline laboratory studies. Tuberculosis testing (PPD) should be performed on all patients who will be treated with TNF inhibitors as there are reports of tuberculosis reactivation in patients treated with this class of drug (AAD).