2018 MIPS Measure #065: Appropriate Treatment for Children with Upper Respiratory Infection (URI)

Measure Description

Percentage of children 3 months-18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode

Instructions

This measure is to be submitted once for each occurrence of upper respiratory infection during the performance period. Claims data will be analyzed to determine unique occurrences. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measurespecific denominator coding.

Measure Submission:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

Denominator

Children age 3 months to 18 years of age who had an outpatient or emergency department (ED) visit with a diagnosis of upper respiratory infection (URI) during the measurement period 

Denominator Instructions: To determine eligibility, look for any of the listed antibiotic drugs below in the 30 days prior to the visit with the URI diagnosis. As long as there are no prescriptions for the listed antibiotics during this time period, the patient is eligible for denominator inclusion. 

Denominator Criteria (Eligible Cases):

Patients aged 3 months to 18 years on date of encounter

AND

Diagnosis for URI (ICD-10-CM): J00, J06.0, J06.9

AND

Patient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99281, 99282, 99283, 99284, 99285, G0402 AND NOT

DENOMINATOR EXCLUSIONS:

Patient prescribed or dispensed antibiotic for documented medical reason(s) (e.g., intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, acute sinusitis, acute pharyngitis, acute tonsillitis, chronic sinusitis, infection of the pharynx/larynx/tonsils/adenoids, prostatitis, cellulitis, mastoiditis, or bone infections, acute lymphadenitis, impetigo, skin staph infections,

pneumonia/gonococcal infections, venereal disease (syphilis, chlamydia, inflammatory diseases [female reproductive organs]), infections of the kidney, cystitis or UTI, and acne: G8709

OR

Children who are taking antibiotics in the 30 days prior to the date of the encounter during which the diagnosis was established: G9701

OR

Patients who use hospice services any time during the measurement period: G9700

Numerator

Children without a prescription for antibiotic medication on or 3 days after the outpatient or ED visit for an upper respiratory infection

Numerator Instructions: For performance, the measure will be calculated as the number of patient’s encounter(s) where antibiotics were neither prescribed nor dispensed on or within three days of the episode for URI over the total number of encounters in the denominator (patients aged 3 months to 18 years with an outpatient or ED visit for URI. A higher score indicates appropriate treatment of patients with URI (e.g., the proportion for whom antibiotics were not prescribed or dispensed following the episode).

 Table 1 – Antibiotic Medications

Numerator Options:

Performance Met:

Patient not prescribed or dispensed antibiotic (G8708)

OR

Performance Not Met:

Patient prescribed or dispensed antibiotic (G8710)