The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year.
This measure is to be submitted a minimum of once per performance period for patients with HIV seen during the performance period. This measure is intended to reflect the quality of services provided for the primary management of patients with HIV.
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.
Patients, regardless of age, with a diagnosis of HIV who had at least one medical visit during the performance period
Denominator Criteria (Eligible Cases):
Patients, regardless of age
Diagnosis of HIV (ICD-10-CM): B20, Z21
Patient encounter during the performance period (CPT or HCPCS): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99424, 99426, G0402
Number of patients with a HIV viral load less than 200 copies/mL at last viral load test
Performance Met: Documentation of viral load less than 200 copies/mL (G9243)
Performance Not Met: Documentation of viral load equal to or greater than 200 copies/mL or viral load not performed (G9242)
Sustained viral load suppression is directly related to reduction in disease progression and to reduction in potential for transmission of infection. Among persons in care, sustained viral load suppression represents the cumulative effect of prescribed therapy, ongoing monitoring, and patient adherence. The measure will direct providers’ attention and quality improvement efforts towards this important outcome.
Clinical Recommendation Statements
Plasma HIV RNA (viral load) should be measured in all patients at baseline and on a regular basis thereafter, especially in patients who are on treatment, because viral load is the most important indicator of response to antiretroviral therapy (ART) (Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents PDF Sections E-1 and C-3. Accessed May 18, 2015) (Strength of Evidence = AI, AIII, BIII). Thus, viral load testing serves as a surrogate marker for treatment response and can be useful in predicting clinical progression (Murray, 1999)
Optimal viral suppression is generally defined as a viral load persistently below the level of detection (<20–75 copies/mL, depending on the assay used). In addition, low-level positive viral load results (typically <200 copies/mL) appear to be more common with some viral load assays than others, and there is no definitive evidence that patients with viral loads quantified as <200 copies/mL using these assays are at increased risk for virologic failure. For the purposes of clinical trials the AIDS Clinical Trials Group (ACTG) currently defines virologic failure as a confirmed viral load >200 copies/mL, which eliminates most cases of apparent viremia caused by blips or assay variability. Effective treatment reduces HIV-associated morbidity and mortality and reduces transmission of HIV (Mocoft, 1998; Palella, 1998; Vittinghoff, 1999; ART CC AC, 2008; Moferson, 1999; Wood, 2009; Quinn, 2000; Dieffernbach, 2009; Montaner, 2006; Cohen, 2011). The mechanism for the impact of treatment is viral load suppression.
Multiple studies demonstrate that viral load suppression is associated with slowing disease progression. Analysis of 18 trials that included more than 5,000 participants with viral load monitoring showed a significant association between a decrease in plasma viremia and improved clinical outcome (Murray, 1999). Viral load testing serves as a surrogate marker for treatment response and can be useful in predicting clinical progression (Hughes, 1997; Marschner, 1998; Thiebaut, 2000). As a result, the Department of Health and Human Services (HHS) Guidelines include a recommendation for measuring viral load at baseline and on a regular basis because viral load is the most important predictor of response to therapy (Strength of Evidence = AI, AIII, BIII). This recommendation is graded AI. The review of the evidence focuses on the evidence for the treatment and prevention recommendations.
The U.S. Department of Health and Human Services Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents recommends antiretroviral therapy for all HIV-infected individuals to reduce the risk of disease progression (Strength of Evidence = AI, AII, and BIII) and well as to prevention transmission of HIV (Strength of Evidence = AI and AIII). These guidelines also recommended the frequency at which viral load testing is to be performed (Strength of Evidence = AI, AIII, BIII) (Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents PDF Sections E-1 and C-3. Accessed May 18, 2015).