Measure Description
Percentage of patients, regardless of age, with a diagnosis of Human Immunodeficiency Virus (HIV) before or during the first 240 days of the performance period who had at least two eligible encounters or at least one eligible encounter and one HIV viral load test that were at least 90 days apart within the performance period.
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. 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
Patients, regardless of age, with a diagnosis of HIV before or during the first 240 days of the performance period who had at least one eligible encounter during the first 240 days of the performance period
DENOMINATOR NOTE: Only patients with an eligible encounter in the first 240 days are included in this measure to allow for sufficient time to complete a second eligible encounter or viral load laboratory at least 90 days after the initial encounter during the performance period.
*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 before or during the first 240 days of the performance period (ICD-10-CM): B20, Z21, B97.35, O98.711, O98.712, O98.713, O98.719, O98.72, O98.73
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, 98966, 98967, 98968, , 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, *, 99242*, 99244*, 99245*, 99341, 99342, 99343, 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
Number of patients who had at least one eligible encounter and one HIV viral load test at least 90 days apart during the performance period, or who had at least two eligible encounters at least 90 days apart during the performance period
NUMERATOR NOTE: A patient would be included in the measure numerator if they have either 1) two eligible encounters at least 90 days apart, or 2) one eligible encounter and one viral load test at least 90 days apart from each other. The encounter or encounters that cause a patient to be included in the numerator do not need to include the encounter that caused the patient to be included in the denominator.
Numerator Options:
Performance Met: Patient had two eligible encounters at least 90 days apart or one eligible encounter and one HIV viral load test at least 90 days apart (G9247)
OR
Performance Not Met: Patient did not have two eligible encounters at least 90 days apart or one eligible encounter and one HIV viral load test at least 90 days apart (G9246)
Rationale
“Retention in care should be routinely monitored. There are various ways to measure retention, including measures based on attended visits over a defined period of time (constancy measures), and measures based on missed visits. Both approaches are valid and independently predict survival. Missed visits and a prolonged time since last visit are relatively easy to measure and should trigger efforts to retain or re-engage a person in care. Constancy measures (e.g., at least two visits that are at least 90 days apart over 1 year, or at least one visit every 6 months over the last 2 years), can be used as clinic quality assurance measures.” (DHHS, Adult, 2025)
Clinical Recommendation Statements
“HIV treatment adherence includes initiating care with an HIV provider (linkage to care), regularly engaging in appointments (retention in care), and adhering to antiretroviral therapy (ART).…This low rate of viral suppression is primarily due to poor adherence to clinic appointments and ART….Knowledgeable providers and high-quality system processes are vital in promoting rapid linkage and sustained retention in care and adherence to ART….Finally, clinicians should recognize that adherence is a complex behavior requiring knowledge, motivation, memory, behavior change, external resources, and successful and persistent interaction with complex and, sometimes, challenging health care systems. The patient–provider relationship is central to improving HIV care engagement and adherence to treatment. Providers must recognize that adherence is a collaborative effort between clinicians and people with HIV.
"Retention in care should be routinely monitored. There are various ways to measure retention, including measures based on attended visits over a defined period of time (constancy measures), and measures based on missed visits. Both approaches are valid and independently predict survival. Missed visits and a prolonged time since last visit are relatively easy to measure and should trigger efforts to retain or re-engage a person in care. Constancy measures (e.g., at least two visits that are at least 90 days apart over 1 year, or at least one visit every 6 months over the last 2 years), can be used as clinic quality assurance measures.” (DHHS, Adult, 2025)
“After initiation of ART or after a change in antiretroviral (ARV) regimen, children should be evaluated for treatment adherence and clinical adverse effects within 1 to 2 weeks; laboratory testing for viral load response and toxicity is recommended at 2 to 4 weeks after treatment initiation or change in ARV regimen and every 3 to 4 months thereafter.
“Clinicians and multidisciplinary teams should schedule frequent clinical in-person and/or telemedicine visits to monitor patients closely during the first few months after initiating a new ARV regimen.” (DHHS, Children, 2025)
REFERENCES:
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. Department of Health and Human Services. Available online. Accessed October 2025. L-2 through L-4.
Panel on Antiretroviral Therapy and Medical Management of HIV-Infected Children. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection. Department of Health and Human Services. Available online. Accessed October 2025. D-1 through D-3.