Measure Description
Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea (OSA) that were prescribed an evidence-based therapy that had documentation that adherence to therapy was assessed at least annually through an objective informatics system or through self-reporting (if objective reporting is not available)
Instructions
This measure is to be submitted a minimum of once per performance period for patients with 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, POS 02, POS 10) are allowable.Please note that effective January 1, 2025, while a measure may be denoted as telehealth eligible, specific denominator codes within the encounter may no longer be eligible due to changes outlined in the CY 2024 PFS Final Rule List of Medicare Telehealth Services.
Measure Submission:
Measure data may be submitted by individual MIPS eligible clinicians, groups, orthird-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 a diagnosis of obstructive sleep apnea who were prescribed an evidencebased therapy
Definition:
Evidence-based Therapy – includes positive airway pressure, oral appliances, positional therapies, hypoglossal nerve stimulation, or other devices with monitoring capabilities.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for obstructive sleep apnea on date of encounter (ICD-10-CM): G47.33
AND
Patient encounter during the performance period (CPT): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016,99202, 99203, 99204, 99205,99211, 99212,99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350
AND
Evidence-based therapy was prescribed: M1227
Numerator
Patients with documentation that adherence to therapy was assessed at least annually through an objective informatics system or through self-reporting (if objective reporting is not available)
Definition:
Documentation of adherence to therapy – includes a note documented in the patient’s medical record that patient is adherent to the prescribed therapy for obstructive sleep apnea.
Objective Informatics – a telemonitoring system that shows data demonstrating patient adherence to the prescribed therapy for obstructive sleep apnea (i.e., CPAP machines with SD cards that store data).
Objective Reporting – data that are reported from an objective informatics or other data source and is not reported by the patient or parent/caregiver.
Self-Reporting – patient and/or parent/caregiver attests to compliance with prescribed therapy for obstructive sleep apnea, which is documented in the medical record.
Numerator Options:
Performance Met: Adherence to therapy was assessed at least annually through an objective informatics system or through selfreporting (if objective reporting is not available, documented) (G8851)
OR
Denominator Exception: Documentation of reason(s) for not objectively reporting adherence to evidence-based therapy (e.g., patients who have been diagnosed with a terminal or advanced disease with an expected life span of less than 6 months, patients who decline therapy, patients who do not return for followup at least annually, patients unable to access/afford therapy, patient’s insurance will not cover therapy) (G8854)
OR
Performance Not Met: Adherence to therapy was not assessed at least annually through an objective informatics system or through selfreporting (if objective reporting is not available), reason not given (G8855)
Rationale
This recommendation is based on evidence that therapy adherence is extremely important for patients with OSA to experience improvement in signs and symptoms of OSA. Although positive airway pressure (PAP) has been the most efficacious therapy and is often the first option for OSA patients. For patients with mild or moderate OSA, oral appliances may also be appropriate therapy. However, some patients find such devices to be intrusive, inconvenient, or intolerable. Surgical modification of the upper airway is also a viable treatment for selected patients (Morgenthaler, 2006).
Under ideal circumstances, patients with inadequate PAP utilization will have had an opportunity to consult with a sleep medicine professional to address barriers to adherence, although access to such resources may be limited in some areas. A threshold for adequate PAP adherence will vary between patients depending on their individual underlying medical history, symptomatology, disease severity, and response to PAP, and should be part of the discussion between the health care provider and patient (Kent, 2021).
OSA is a chronic disease that rarely resolves except with substantial weight loss or successful corrective surgery. As with other chronic diseases, periodic follow-up by a qualified clinician (eg, physician or advanced practice provider) is necessary to confirm adequate treatment, assess symptom resolution, and promote continued adherence to treatment. Initial treatment of OSA requires close monitoring and early identification of difficulties with PAP use, as adherence over the first few days to weeks has been shown to predict long-term adherence. Objective monitoring of PAP therapy should be performed to complement patient reporting of difficulties with PAP use, as patients often overestimate their use of PAP treatment. (Patil, et al, 2019)
PAP therapy remains the gold standard for treating OSA. Alternative approaches may be appropriate for patients unable to tolerate PAP. Untreated OSA can cause daytime sleepiness, reduced productivity, increased accident risk, and worsening cardiovascular conditions such as hypertension, atrial fibrillation, and stroke (Pavwoski, et al, 2017).
Clinical Recommendation Statements
The AASM Treatment of Adult Obstructive Sleep Apnea with Positive Airway Pressure clinical practice guideline recommends that clinicians use positive airway pressure, compared to no therapy, to treat OSA in adults with excessive sleepiness (Patil, 2019).
The AASM Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy clinical practice guideline update recommends that sleep physicians prescribe oral appliances, rather than no therapy, for adult patients who request treatment of primary snoring (without obstructive sleep apnea) (Ramar, 2015).
The AASM Referral of Adults with Obstructive Sleep Apnea for Surgical Consultation clinical practice guideline recommends that clinicians discuss referral to a sleep surgeon with adults with OSA and BMI < 40 kg/m2 who are intolerant or unaccepting of PAP as part of a patient-oriented discussion of alternative treatment options (Kent, 2021).
The AASM Referral of Adults with Obstructive Sleep Apnea for Surgical Consultation clinical practice guideline recommends that clinicians discuss referral to a bariatric surgeon with adults with OSA and obesity (class II/III, BMI ≥ 35) who are intolerant or unaccepting of PAP as part of a patient-oriented discussion of alternative treatment options (Kent, 2021).
The AASM Referral of Adults with Obstructive Sleep Apnea for Surgical Consultation clinical practice guideline suggests that clinicians discuss referral to a sleep surgeon with adults with OSA, BMI < 40 kg/m2, and persistent inadequate PAP adherence due to pressure-related side effects as part of a patient-oriented discussion of adjunctive or alternative treatment options (Kent, 2021).
The AASM Referral of Adults with Obstructive Sleep Apnea for Surgical Consultation clinical practice guideline suggests that clinicians recommend PAP as initial therapy for adults with OSA and a major upper airway anatomic abnormality prior to consideration of referral for upper airway surgery (Kent, 2021).
Adequate follow-up, including troubleshooting and monitoring of objective efficacy and usage data to ensure adequate treatment and adherence, should occur following PAP therapy initiation and during treatment of OSA (Patil et al, 2019).