Measure Description
Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI), a respiratory disturbance index (RDI), or a respiratory event index (REI) documented or measured within 2 months of initial evaluation for suspected obstructive sleep apnea.
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 (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
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, 99341, 99342, 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), a respiratory disturbance index (RDI), or a respiratory event index (REI) documented or measured within 2 months of initial evaluation for suspected obstructive sleep apnea
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).
Respiratory Event Index (REI) – is a measure of respiratory events per unit of time for a home sleep apnea test.
NUMERATOR NOTE: The quality data codes below should be used for assessment of a MIPS eligible clinician’s actions within 2 months of the initial evaluation for obstructive sleep apnea. If there is not adequate time for measuring an apnea hypopnea index (AHI), a respiratory disturbance index (RDI), or a respiratory event index (REI) (e.g., initial evaluation was conducted in December of the performance period), report the denominator exception.
Numerator Options:
Performance Met: Apnea hypopnea index (AHI), respiratory disturbance index (RDI) or respiratory event index (REI) documented or measured within 2 months of initial evaluation for suspected obstructive sleep apnea (G8842)
OR
Denominator Exception: Documentation of reason(s) for not measuring an apnea hypopnea index (AHI), a respiratory disturbance index (RDI), or a respiratory event index (REI) within 2 months of initial evaluation for suspected obstructive sleep apnea (e.g., medical, neurological, or psychiatric disease that prohibits successful completion of a sleep study, patients for whom a sleep study would present a bigger risk than benefit or would pose an undue burden, dementia, patients who decline AHI/RDI/REI measurement, patients who had a financial reason for not completing testing, test was ordered but not completed, patients decline because their insurance (payer) does not cover the expense) (G8843)
OR
Performance Not Met: Apnea hypopnea index (AHI), respiratory disturbance index (RDI), or respiratory event index (REI) not documented or measured within 2 months of initial evaluation for suspected obstructive sleep apnea, 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 comorbid 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). AHI or REI <5/hour = normal (for adults); 5–14.9/hour = mild OSA; 15–29.9/hour = moderate OSA; and ≥30/hour = severe OSA (Goyal et al, 2017). 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) The severity of OSA is determined by an index – Apnea Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI), if PSG is performed, or Respiratory Event Index (REI) if out-of-center-sleep testing (OCST) is performed (Goyal et al, 2017).