Measure Description
Percentage of patients, regardless of age, diagnosed with HIV prior to or during the first 90 days of the performance period, with an eligible encounter in the first 240 days of the performance period, whose last HIV viral load test result was less than 200 copies/mL during the performance period.
Instructions
This measure is to be submitted a minimum of once per performance period for patients with HIV seen during the first 240 days of the performance period. This measure is intended to reflect the quality of services provided for the primary management of patients with HIV. HIV viral load test results may be expressed as log values (log copies/mL). Please convert the log value to copies/mL.
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. 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 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, regardless of age, diagnosed with HIV prior to or during the first 90 days of the performance period with at least one eligible encounter in the first 240 days of the performance period
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, regardless of age
AND
Diagnosis of HIV prior to the performance period or during the first 90 days of the performance period (ICD-10-CM): B20, B97.35, Z21, O98.711, O98.712, O98.713, O98.719, O98.72, O98.73
AND
Patient encounter during the first 240 days of the performance period (CPT or HCPCS): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98966, 98967, 98968, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99242*, 99244*, 99245*, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, 99429*, G0402, G0438, G0439
Numerator
Patients with a last HIV viral load test result of less than 200 copies/mL during the performance period
Numerator Options:
Performance Met: Documentation of viral load less than 200 copies/mL (G9243)
OR
Performance Not Met: Documentation of viral load equal to or greater than 200 copies/mL or viral load not performed (G9242)
Rationale
“Antiretroviral therapy (ART) has reduced HIV-related morbidity and mortality at all stages of HIV infection and has reduced HIV transmission. Maximal and durable suppression of plasma viremia delays or prevents the selection of drug-resistance mutations, preserves or improves CD4 T lymphocyte (CD4) cell numbers, and confers substantial clinical benefits, all of which are important treatment goals. HIV suppression with ART may also decrease inflammation and immune activation thought to contribute to higher rates of cardiovascular and other end-organ damage reported in cohorts with HIV. Despite these benefits, eradication of HIV infection cannot be achieved with available antiretrovirals (ARVs). Treatment interruption has been associated with rebound viremia, worsening of immune function, and increased morbidity and mortality. Thus, once initiated, ART should be continued, with the following key treatment goals: maximally and durably suppress plasma HIV RNA; restore and preserve immunologic function; reduce HIVassociated morbidity and prolong the duration and quality of survival; and prevent HIV transmission.” (DHHS Adult and Adolescent, 2025)
Clinical Recommendation Statements
Adult guidelines:
"These guidelines now define virologic failure as the inability to achieve or maintain suppression of viral replication to HIV RNA levels of <200 copies/mL—a threshold that eliminates most cases of apparent viremia caused by viral load blips or assay variability. “Individuals who are adherent to their antiretroviral regimens and do not harbor resistance mutations to the component drugs can generally achieve suppression 8 to 12 weeks after ART initiation or after modification due to virologic failure; "The primary goals of antiretroviral therapy (ART) are to prevent HIV-associated morbidity and mortality and to prevent transmission of HIV to others. These goals are accomplished by using effective ART to achieve and maintain plasma HIV-1 RNA levels (viral load) below the quantification limits of commercially available assays. Durable viral suppression lowers the risk of both AIDS defining and other HIV-related complications, improves immune function and overall health, and allows people with HIV to live a lifespan approaching that of people without HIV. High plasma viral load is a major risk factor for HIV transmission; effective ART suppresses viremia and, consequently, substantially reduces the risk of sexual and perinatal HIV transmission. Modeling studies and ecological studies of populations with high ART uptake and high viral suppression rates suggest that expanded use of ART lowers the incidence of HIV and, eventually, the prevalence of HIV on a community or population level.
"The Panel on Antiretroviral Guidelines for Adults and Adolescents (the Panel) recommends ART for all people with HIV to reduce the morbidity and mortality associated with HIV infection (AI) and to prevent HIV transmission to sexual partners and infants (AI). ART should be initiated as soon as possible after HIV diagnosis (AII).” (DHHS Adult and Adolescent, 2025)
Pediatric guidelines:
"Based on accumulated experience with currently available assays, the current definition of virologic suppression is a plasma viral load that is below the quantification limit of the assay used (generally <20 copies/mL to 75 copies/mL). This definition of suppression has been much more thoroughly investigated in adults with HIV than in children with HIV (see the Adult and Adolescent Antiretroviral Guidelines). Temporary viral load elevations (“blips”) are often detected in adults on ART and generally defined as up to 200 copies/mL, but they may be as high as 500 copies/mL in children on ART; these temporary elevations do not represent virologic failure as long as the values have returned to below the level of detection when testing is repeated. For definitions and management of virologic treatment failure, see Recognizing and Managing Antiretroviral Treatment Failure. These definitions of virologic suppression and virologic failure are recommended for clinical use. Research protocols or surveillance programs may use different definitions.” (DHHS, Children, 2025)