2021 MIPS Measure #261: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness

Measure Description

Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness

Instructions

This measure is to be submitted a minimum of once per performance period for all patients seen during the performance period who present with acute or chronic dizziness. This measure is intended to ensure that patients with acute or chronic dizziness receive a referral in order to receive appropriate care. 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

All patients aged birth and older presenting with acute or chronic dizziness

Denominator Criteria (Eligible Cases):

Patients aged birth and older

AND

Diagnosis for Dizziness (ICD-10-CM): H81.10, H81.11, H81.12, H81.13, R42

AND

Patient encounter during the performance period (CPT): 92540, 92541, 92542, 92544, 92545, 92546, 92548, 92550, 92557, 92567, 92568, 92570, 92575

Numerator

Patients referred to a physician for an otologic evaluation subsequent to an audiologic evaluation who present with acute or chronic dizziness

NUMERATOR NOTE: The physician receiving the referral, or providing care currently, should preferably be specially trained in disorders of the ear. Denominator exception will be determined on the date of the denominator eligible encounter.

Numerator Options:

Performance Met: Referral to a physician for an otologic evaluation performed (G8856)

OR

Denominator Exception: Patient is not eligible for the referral for otologic evaluation measure (e.g., patients who are already under the care of a physician for acute or chronic dizziness) (G8857)

OR

Performance Not Met: RReferral to a physician for an otologic evaluation not performed, reason not given (G8858)

Rationale

Studies demonstrate that patients who present with acute or chronic dizziness may suffer from underlying problems, so therefore referral is necessary. Without referral, patients may suffer consequences of the underlying problems.

Clinical Recommendation Statements

The American Academy of Otolaryngology-Head and Neck Surgery policy statement (approved 9/12/2002):

Hearing loss and balance disorders are medical conditions. Only licensed physicians with medical training may diagnose and direct the management of disease and medical disorders. A full history and physical examination by a physician (preferably a physician specially trained in disorders of the ear) to determine the accurate medical diagnosis and appropriate medical/surgical treatment for hearing loss and balance disorders are indicated for patients with the following “red flags”:

1. Hearing loss with a positive history of familial hearing loss, TB, syphilis, HIV, Meniere’s disease, autoimmune disorder, otosclerosis, von Recklinghausen’s neurofibromatosis, Paget’s disease of bone, head trauma related to onset.
2. History of pain, active drainage, or bleeding from an ear.
3. Sudden onset or rapidly progressive hearing loss.
4. Acute, chronic, or recurrent episodes ofdizziness.
5. Evidence of congenital or traumatic deformity of the ear.
6. Visualization of blood, pus, cerumen plug, or foreign body in the ear canal.
7. Conductive hearing loss or abnormal tympanogram.
8. Unilateral or asymmetric hearing loss; or bilateral hearing loss > 80 dB.
9. Unilateral or pulsatile tinnitus.
10. Unilateral or asymmetrically poor speech discrimination scores.

The red flags do not include all indications for a medical referral and are not intended to replace clinical judgment in determining the need for consultation with an otolaryngologist.

21 C.F.R. Section 801.420:

A hearing aid dispenser should advise a prospective hearing aid user to consult promptly with a licensed physician (preferably an ear specialist) before dispensing a hearing aid if the hearing aid dispenser determines through inquiry, actual observation, or review of any other available information concerning the prospective user, that the prospective user has any of the following conditions:

1. Visible congenital or traumatic deformity of the ear.
2. History of active drainage from the ear within the previous 90 days.
3. History of sudden or rapidly progressive hearing loss within the previous 90 days.
4. Acute or chronic dizziness.
5. Unilateral hearing loss of sudden or recent onset within the previous 90 days.
6. Audiometric air-bone gap equal to or greater than 15 decibels at 500 hertz (Hz), 1,000 Hz, and 2,000 Hz