Measure Description
Percentage of patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between medical visits.
Instructions
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. 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
Patients, regardless of age, with a diagnosis of HIV with at least one medical visit in the performance period
DENOMINATOR NOTE: In order to determine denominator eligibility, patients should be diagnosed with HIV during the first 3 months of the 24-month measurement period or have a diagnosis prior to the 24- month measurement period. The 24-month measurement period is defined as the 24 months prior to and including the date of the first qualifying encounter during the performance period (i.e., January 1, 2024 through December 31, 2024). Performance of the measure is met when there is at least one medical visit in each 6-month interval with 60 days between denominator eligible encounters for patients with HIV within the 24-month measurement period.
Denominator Criteria (Eligible Cases):
Patients, regardless of age
AND
Diagnosis of HIV (ICD-10-CM): B20, Z21
AND
Patient encounter during the performance period (CPT or HCPCS): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99424, 99426, G0402
AND NOT
DENOMINATOR EXCLUSION:
Patient died at any time during the 24‐month measurement period: G9751
Numerator
Number of patients who had at least one medical visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between medical visits
Numerator Options:
Performance Met: Patient had at least one medical visit in each 6- month period of the 24-month measurement period, with a minimum of 60 days between medical visits (G9247)
OR
Performance Not Met: Patient did not have at least one medical visit in each 6- month period of the 24-month measurement period, with a minimum of 60 days between medical visits (G9246)
Rationale
Early linkage to and long-term retention in HIV care leads to better health outcomes. Linkage to HIV medical care shortly after HIV diagnosis and continuous care thereafter provide opportunities for risk reduction counseling, initiation of treatment, and other strategies that improve individual health and prevent onward transmission of infection (Giordano, 2007; Cohen, 2011; Giordano, 2003; Lucas, 1999; Metscher, 2008; Montaner, 2010). Delayed linkage and poor retention in care are associated with delayed receipt of antiretroviral treatment, higher rate of virologic failure, and increased morbidity and mortality (Metscher, 2008; Montaner, 2010; Ulett, 2009).
Poor retention in care during the first year of outpatient medical care is associated with delayed or failed receipt of antiretroviral therapy, delayed time to virologic suppression and greater cumulative HIV burden, increased sexual risk transmission behaviors, increased risk of long-term adverse clinical events, and low adherence to antiretroviral therapy (Giordano, 2007; Metscher, 2008; Ulett, 2009; Mugavero, 2009). Early retention in HIV care has been found to be associated with time to viral load suppression and 2-year cumulative viral load burden among patients newly initiating HIV medical care (Mugavero, 2012). In this study, each “no show” clinic visit conveyed a 17% increased risk of delayed viral load suppression. A dose- response relationship has been shown between constancy of visits during the first year (i.e. having an HIV primary care visit in each 3-month quarter) and survival (Mugavero, 2009). Another study examining care over a two year period has found that mean increase from baseline CD4 counts was significantly greater among those with optimal retention (visits in all 4 six-month intervals) than among those with sub-optimal retention, and that mortality was higher among those with suboptimal retention (Tripathi, 2011).
In an analysis of 9 years (January 1, 2001 through December 31, 2009) of outpatient HIV care utilization from 17, 425 HIV infected adults enrolled in the HIV Research Network (HIVRN), a consortium of HIV care clinics, Yehia et al. found that 7179 (41.6%) individuals never experienced an interval between outpatient visits longer than 6 months (no gap), 5426 (31.1%) had one or more 7–12-month gaps in care, and 4820 (27.7%) had one or more gaps of longer than 12 months.
Clinical Recommendation Statements
U.S. Department of Health and Human Service (HHS) guidelines make recommendations regarding the types and frequency of screenings, laboratory testing, and counseling that should be provided to people living with HIV. Screening, testing, and counseling are delivered through comprehensive HIV medical care visits. The frequency of the medical visit are related to the individual patient’s health status and attainment of health outcomes. Based on the frequency of screenings, testing, and counseling, HIV medical visits should occur every six months. (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).