Measure Description
Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting period
Instructions
This measure is to be submitted a minimum of once per performance period for all patients, regardless of age, who are active injection drug users 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.
NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.
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, regardless of age, who are seen twice for any visit or who had at least one preventive visit within the 12- month reporting period who are active injection drug users
Definition:
Active injection drug users – Those who have injected any drug(s) within the 12-month reporting period.
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):
Documentation of active injection drug use: G9518
AND
At least one preventive encounter during the performance period (CPT or HCPCS): 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, G0438, G0439
OR
At least two patient encounters during the performance period (CPT): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
AND NOT
DENOMINATOR EXCLUSION:
Diagnosis for Chronic Hepatitis C (ICD-10-CM): B18.2
Numerator
Patients who received screening for HCV infection within the 12-month reporting period
Definition:
Screening for HCV infection – includes HCV antibody test or HCV RNA test.
NUMERATOR NOTE: Denominator Exception(s) are determined on the date of the most recent denominator eligible encounter.
Numerator Options:
Performance Met: Patient received screening for HCV infection within the 12-month reporting period (G9383)
OR
Denominator Exception: Documentation of medical reason(s) for not receiving annual screening for HCV infection (e.g., decompensated cirrhosis indicating advanced disease [i.e., ascites, esophageal variceal bleeding, hepatic encephalopathy], hepatocellular carcinoma, waitlist for organ transplant, limited life expectancy, other medical reasons) (G9384)
OR
Denominator Exception: Documentation of patient reason(s) for not receiving annual screening for HCV infection (e.g., patient declined, other patient reasons) (G9385)
OR
Performance Not Met: Screening for HCV infection not received within the 12- month reporting period, reason not given (G9386)
Rationale
Of the estimated 3.5 million people living in the United States with the hepatitis C virus infection (HCV), only 50% have been tested for HCV and are aware of their status. Reported cases of HCV have increased (approximately 20% per year) between 2010-2016, which is only partially due to improved case detection and more likely due to rising rates of injection drug use. Additionally, only one third have been referred for HCV care and only 5.6% receive recommended treatment. Studies indicate that even among high-risk patients for whom screening is recommended, only 49-75% are aware of their infection status. In a recent analysis of data from a national health survey, 67.9 % of persons ever infected with HCV reported an exposure risk, (e.g., injection drug use, having sexual contact with suspected/confirmed hepatitis C patient), 2 weeks to 6 months prior to symptom onset, and the remaining 32.1% reported no known exposure risk. Data from the CDC shows that of the 2016 case reports that had information about drug use, 68.6% reported the use of injection drugs. According to one study, 72% of persons with a history of injection-drug use who are infected with HCV remain unaware of their infection status. Current risk-based testing strategies have had limited success, as evidenced by the substantial number of HCV-infected persons who remain unaware of their infection. As a result, many do not receive needed care (e.g., education, counseling, and medical monitoring), and are not evaluated for treatment. HCV causes acute infection, which can be characterized by mild to severe illness but is usually asymptomatic. In approximately 75%-85% of persons, HCV persists as a chronic infection, placing infected persons at risk for liver cirrhosis, hepatocellular carcinoma (HCC), and extrahepatic complications that develop over the decades following onset of infection.
Since 1998, routine HCV testing has been recommended by CDC for persons most likely to be infected with HCV. These recommendations were made on the basis of a known epidemiologic association between a risk factor and acquiring HCV infection, including injection drug use. It is estimated that most new cases of HCV infections are among young persons who are white, live in non-urban areas and have a history of previously reported injection drug use. An epidemic has arisen that is a national priority for federal and state public health agencies. HCV testing is the first step toward improving health outcomes for persons who report injection drug use and are infected with HCV.
Clinical Recommendation Statements
Verbatim from AASLD and IDSA Recommendations for Testing, Managing, and Treating Hepatitis C, September 2017:
Annual HCV testing is recommended for persons who inject drugs and for HIV-infected men who have unprotected sex with men. Periodic testing should be offered to other persons with ongoing risk factors for HCV exposure. (Rating: Class IIA, Level C) (AASLD/IDSA, 2017)
The USPSTF recommends screening for hepatitis C virus (HCV) infection in persons at high risk for infection. The USPSTF also recommends offering 1-time screening for HCV infection to adults born between 1945 and 1965. (Grade B recommendation) (USPSTF, 2013)
Assessment of Risk
The most important risk factor for HCV infection is past or current injection drug use. Another established risk factor for HCV infection is receipt of a blood transfusion before 1992. Because of the implementation of screening programs for donated blood, blood transfusions are no longer an important source of HCV infection. In contrast, 60% of new HCV infections occur in persons who report injection drug use within the past 6 months. Additional risk factors include long-term hemodialysis, being born to an HCV-infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneous exposures (such as in health care workers or from having surgery before the implementation of universal precautions). Evidence on tattoos and other percutaneous exposures as risk factors for HCV infection is limited. The relative importance of these additional risk factors may differ on the basis of geographic location and other factors. (USPSTF, 2013)