2024 MIPS Measure #065: Appropriate Treatment for Upper Respiratory Infection (URI)

Measure Description

Percentage of episodes for patients 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic order.

Instructions

This measure is to be submitted once for each occurrence of upper respiratory infection during the performance period. Claims data will be analyzed to determine unique occurrences. 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 (including but not limited to encounters coded with GQ, GT, 95, POS 02, POS 10) 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

Outpatient visits, telephone visits, online assessments (i.e., e-visit or virtual check-in), observation stays or emergency department visits with a diagnosis of upper respiratory infection (URI) from January 1 to December 28 for patients 3 months of age and older

Denominator Instructions:

This is an episode of care measure that examines all eligible episodes for the patient. If the patient has more than one episode in a 31-day period, include only the first episode. An episode is defined as each eligible encounter for patients aged 3 months of age and older with a diagnosis of upper respiratory infection during the measurement period of January 1 to December 28.

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 aged 3 months of age and older on date of encounter

AND

Diagnosis for URI (ICD-10-CM): J00, J06.0, J06.9

AND

Patient encounter during the measurement period (CPT or HCPCS): 98966, 98967, 98968, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99421, 99422, 99423, 99441, 99442, 99443, 99455, 99456, 99457, 98980, G2250, G2251, G2252

WITHOUT

Place of Service (POS): 21

AND NOT

DENOMINATOR EXCLUSIONS:

URI 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): G2173

OR

URI episodes where the patient is taking antibiotics (Table 1) in the 30 days prior to the episode date: G2174

OR

URI episodes when the patient had competing diagnoses on or three days after the episode date (e.g., intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, acute sinusitis, acute pharyngitis, acute tonsillitis, chronic sinusitis, infection of the pharynx/larynx/tonsils/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, and acne): G8709

OR

Patients who use hospice services any time during the measurement period: G9700

Table 1 - Antibiotic Medications

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

Numerator

URI episodes without a prescription for antibiotic medication (Table 1) on or within 3 days after the outpatient visit, telephone visit, online assessment, observation stay or emergency department visit for an upper respiratory infection

Numerator Instructions:

For performance, the measure will be calculated as the number of patient’s encounter(s) where antibiotics from Table 1 were not prescribed on or within three days of the episode for URI over the total number of encounters in the denominator. A higher score indicates appropriate treatment of patients with URI (e.g., the proportion for whom antibiotics were not prescribed following the episode). Delayed prescriptions (where an antibiotic was prescribed and patient was instructed to delay taking the antibiotic) are considered “Performance Not Met”.

Numerator Options:

Performance Met: Patient not prescribed antibiotic (G8708)

OR

Performance Not Met: Patient prescribed antibiotic (G8710)

Rationale

Most upper respiratory infections (URI), also known as the common cold, are caused by viruses that require no antibiotic treatment. Too often, antibiotics are prescribed inappropriately, which can lead to antibiotic resistance (when antibiotics can no longer cure bacterial infections). In the United States, at least 2.8 million antibiotic-resistant illnesses and 35,000 deaths occur each year.

Clinical Recommendation Statements

American Family Physician (Fashner, Ericson, and Werner, Khilberg 2012)

- Antibiotics should not be used for the treatment of cold symptoms in children or adults. (A)

- Nonsteroidal anti-inflammatory drugs reduce pain secondary to upper respiratory tract infection in adults. (A)

- Decongestants, antihistamine/decongestant combinations, and intranasal ipratropium (Atrovent) may improve cold symptoms in adults. (B)

Institute for Clinical Systems Improvement (Short, et al, 2017)

-The ICSI work group does not recommend antibiotics for treatment of common cold symptoms in children and adults.