2023 MIPS Measure #066: Appropriate Testing for Pharyngitis

Quality ID 066
eMeasure ID CMS146v11
High Priority Measure Yes
Specifications EHR Registry
Measure Type Process
Specialty Emergency Medicine Family Medicine Otolaryngology Pediatrics Urgent Care

Measure Description

The percentage of episodes for patients 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic order and a group A streptococcus (strep) test in the seven-day period from three days prior to the episode date through three days after the episode date



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 ordered 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.

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.



Outpatient, telephone, online assessment (i.e. e-visit or virtual check-in), observation, or emergency department (ED) visits with a diagnosis of pharyngitis or tonsilitis and an antibiotic order on or within 3 days after the episode date among patients 3 years or older

Denominator Instruction:

This is an episode of care measure that examines all eligible episodes for the patient during the measurement period. The intent is to determine whether antibiotics are being ordered appropriately. Antibiotics should only be ordered if a strep test has been performed to confirm a bacterial infection. Antibiotics should not be ordered for viral infections. Antibiotics should be ordered on the episode date through three days after the episode date.

An episode is defined as each eligible encounter for patients aged 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic order during the measurement period.

If a patient has more than one eligible episode in a 31-day period, include only the first eligible episode.

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 3 years of age or older on date of encounter


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


Patient encounter during the performance period (CPT or HCPCS): 98966, 98967, 98968, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99238, 99239, 99242*, 99243*,99244*, 99245*, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*


Prescribed antibiotic on or within 3 days after the episode date (Table 1): G8711



Episodes where the patient is taking antibiotics (Table 1) in the 30 days prior to the episode date, or had an active prescription on the episode date: G9703


Episodes where the patient had a comorbid condition during the 12 months prior to or on the episode date (e.g., tuberculosis, neutropenia, cystic fibrosis, chronic bronchitis, pulmonary edema, respiratory failure, rheumatoid lung disease): G2175


Episodes where the patient had a competing diagnosis on or within three days after the episode date (e.g., intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, acute sinusitis, chronic sinusitis, infection of the 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


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

Table 1 - Antibiotic Medications

Note: This list should be used when assessing antibiotic prescriptions for the denominator and denominator exclusion components.




• Amoxicillin

• Ampicillin 

Beta-lactamase inhibitors

• Amoxicillin-clavulanate


First generation cephalosporins

• Cefadroxi

• Cefazolin

• Cephalexin

Folate antagonist

• Trimethoprim


Lincomycin derivatives

• Clindamycin



• Azithromycin

• Clarithromycin

• Erythromycin

• Erythromycin ethylsuccinate

• Erythromycin lactobionate

• Erythromycin stearate

Natural penicillins

• Penicillin G potassium

• Penicillin G sodium

• Penicillin V potassium

• Pencicillin G benzathine

Penicillinase-resistant penicillins

• Dicloxacillin



• Ciprofloxacin

• Levofloxacin

• Moxifloxacin

• Ofloxacin

Second generation cephalosporins

• Cefaclor

• Cefprozil

• Cefuroxime


• Sulfamethoxazole-trimethoprim



• Doxycycline

• Minocycline

• Tetracycline

Third generation cephalosporins

• Cefdinir

• Cefixime

• Cefpodoxime

• Ceftibuten

• Cefditoren

• Ceftriaxone



A group A streptococcus test in the seven-day period from three days prior to the episode date through three days after the episode date

Numerator Instruction:

A higher score indicates appropriate treatment of children with pharyngitis (e.g., the proportion for whom antibiotics were prescribed with an accompanying strep test. The test must be performed to confirm a bacterial infection prior to the antibiotic order).

Numerator Options:

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


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



Group A streptococcal (GAS) 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) (Pfoh et al., 2008).


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”

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