Measure Description
Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis
Instructions
This measure is to be submitted a minimum of once per performance period for patients with a diagnosis of sleep apnea 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 aged 18 years and older with an initial diagnosis of sleep apnea
DENOMINATOR NOTE: Denominator eligible encounters only include those where the initial diagnosis of sleep apnea is present in the medical documentation or it is the MIPS eligible clinician’s first encounter with a patient diagnosed with sleep apnea as represented in the coding below.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for sleep apnea (ICD-10-CM): G47.30, G47.33
AND
Patient encounter during the performance period (CPT): 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 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
Encounter corresponds to initial diagnosis of sleep apnea or first contact with sleep apnea diagnosed patient
Numerator
Patients who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis
Definitions:
Apnea-Hypopnea Index (AHI) – for polysomnography performed in a sleep lab is defined as (Total Apneas + Hypopneas per hour of sleep); “Apnea-Hypopnea Index (AHI)” for a home sleep study is defined as (Total Apneas + Hypopneas per hour of monitoring).
Respiratory Disturbance Index (RDI) – is defined as (Total Apneas + Hypopneas + Respiratory Effort Related Arousals per hour of sleep).
NUMERATOR NOTE: The quality data codes below should be used for assessment of a MIPS eligible clinician’s actions either at the time sleep apnea is initially diagnosed or at the initial encounter with a patient previously diagnosed with sleep apnea.
Numerator Options:
Performance Met: Apnea hypopnea index (AHI) or respiratory disturbance index (RDI) measured at the time of initial diagnosis (G8842)
OR
Denominator Exception: Documentation of reason(s) for not measuring an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) at the time of initial diagnosis (e.g., psychiatric disease, dementia, patient declined, financial, insurance coverage, test ordered but not yet completed)(G8843)
OR
Performance Not Met: Apnea hypopnea index (AHI) or respiratory disturbance index (RDI) not measured at the time of initial diagnosis, reason not given (G8844)
Rationale
For patients with obstructive sleep apnea (OSA), the desired outcome of treatment includes the resolution of the clinical signs and symptoms of OSA and the normalization of the apnea hypopnea index (AHI) and oxyhemoglobin saturation. Physicians treating patients with OSA should calculate the patient’s level of severity, which informs risk for other co-morbid conditions and complications. Numerous Level 1 and Level 2 studies have shown that the risk of cardiovascular complications is established for patients with an AHI over 15 (Kushida et al, 2005). Patients with a respiratory disturbance index equal to or greater than 15 are considered to have moderate to severe OSA and should be treated with positive airway pressure therapy
Clinical Recommendation Statements
Moderate sleep apnea is defined as having an RDI of equal to or greater than 15, but less than 30 episodes per hour of sleep; severe sleep apnea is defined as having an RDI equal to or greater than 30 episodes per hour of sleep. These patients are at higher risk for severe cardiovascular diseases and other co-morbid conditions (Kushida et al, 2006). Polysomnography is indicated for positive airway pressure (PAP) titration in patients with sleep related breathing disorders (Level 1). PSG with CPAP titration is appropriate for patients with any of the following results: a) an RDI of at least 15 per hour, regardless of the patient’s symptoms; b) an RDI of at least 5 per hour in a patient with excessive daytime sleepiness. (Kushida et al, 2005)