CMS 146v11: Appropriate Testing for Pharyngitis

Measure: The percentage of episodes for patients 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic order and a group A streptococcus (strep) test in the seven-day period from three days prior to the episode date through three days after the episode date
Measure Type	High Priority Measure	Scoring
Process	Yes	A higher percentage indicates better quality

Denominator	Outpatient, telephone, online assessment (i.e. e-visit or virtual check-in), observation, or emergency department (ED) visits with a diagnosis of pharyngitis or tonsillitis and an antibiotic order on or within 3 days after the episode date among patients 3 years or older
Numerator	A group A streptococcus test in the 7-day period from 3 days prior to the episode date through 3 days after the episode date
Denominator Exceptions	None
Denominator Exclusions	Exclude: Episodes where the patient is taking antibiotics in the 30 days prior to the episode date, or had an active prescription on the episode date Episodes where the patient had a comorbid condition during the 12 months prior to or on the episode date Episodes when the patient had hospice care for any part of the measurement period Episodes where the patient had a competing diagnosis on or within three days after the episode date

Setup Note

This eCQM requires a lab interface to be met. Customers interested in a lab interface should contact Sevocity Support to begin the process of a new interface setup. Interface setup requirements and fees vary per request.

Denominator

Patients who meet the following criteria will be included in the denominator:

Age is ≥ 3 years at the beginning of the Measurement Period
AND
Have at least one eligible encounter with an active diagnosis of pharyngitis or tonsillitis during the Measurement Period finalized by the EC
AND
Have an antibiotic prescribed on the day of the eligible encounter or in the 3 days after the encounter

Encounter Codes Eligible for Denominator

CPT: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99241, 99242, 99243, 99244, 99245, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99429, 99455, 99456, 98966, 98967, 98968, 99441, 99442, 99443, 98969, 98970, 98971, 98972, 99421, 99422, 99423, 99458

HCPCS: G0071, G2010, G2012, G2061, G2062, G2063

Diagnosis

Diagnoses are documented in the Assessment tab of an encounter. The eligible diagnosis codes for pharyngitis and tonsillitis are:

Acute Pharyngitis

ICD-10: J02.0, J02.8, J02.9

Acute Tonsillitis

ICD-10: J03.00, J03.01, J03.80, J03.81, J03.90, J03.91

Medication

To prescribe a medication, go to Encounter > Medications > Manage/Prescribe Meds > New Prescription. A comprehensive list of eligible antibiotic medications for pharyngitis can be located here.

Denominator Exclusions

A patient will be excluded from this measure if they meet any of the following conditions:

Was prescribed an antibiotic in the 30 days before or on the day they were diagnosed with pharyngitis or tonsillitis
Has an encounter with an active diagnosis for a competing condition within three days after the qualifying encounter date
Has an encounter with a comorbid condition during the 12 months prior to or on the qualifying encounter date
Is in hospice care for any part of the Measurement Period

Medication

To prescribe a medication, go to Encounter > Medications > Manage/Prescribe Meds > New Prescription. A comprehensive list of eligible antibiotic medications can be located here.

Encounter with Competing Condition

A patient with an active diagnosis for a competing condition—assessed in the three days after the denominator-eligible encounter—will be excluded from this measure.

For this measure, a competing condition is a diagnosis different from the denominator-eligible diagnosis for which it is appropriate to prescribe an antibiotic. Examples of a competing condition include otitis media, sinusitis, and pneumonia.

Diagnosis

Diagnoses are documented in the Assessment tab of an encounter. A comprehensive list of eligible diagnosis codes for competing conditions can be located here.

Encounter Codes Eligible for Denominator Exclusion

HCPCS: G0071, G2010, G2012, G2061, G2062, G2063

Encounter with Comorbid Condition

A patient with an active diagnosis for a comorbid condition—assessed on the day of the denominator-eligible encounter or in the 12 months prior—will be excluded from this measure.

For this measure, a comorbid condition is a diagnosis different from the denominator-eligible diagnosis for which it is appropriate to prescribe an antibiotic. Examples of a comorbid condition include tuberculosis and atelectasis.

Diagnosis

Diagnoses are documented in the Assessment tab of an encounter. A comprehensive list of eligible diagnosis codes for comorbid conditions can be located here.

Encounter Codes Eligible for Denominator Exclusion

HCPCS: G0071, G2010, G2012, G2061, G2062, G2063

Hospice Care Services

To document hospice care ambulatory services, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

CPT: 99377, 99378

HCPCS: G0182

Order Status must be marked as Pending or Complete.

To document hospice care encounter services, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

HCPCS: G9996, G9473, G9474, G9475, G9476, G9477, G9478, G9479, Q5003, Q5004, Q5005, Q5006, Q5007, Q5008, Q5010, S9126, T2042, T2043, T2044, T2045, T2046

Order Status must be marked as Complete.

Numerator

A patient will be counted in the numerator if they received a group A strep test with result in the 3 days before their eligible encounter, on the day of their eligible encounter, or in the 3 days after their eligible encounter.

To document that a group A strep was performed, an e-Lab result for the test must be stored in the patient chart.

Store an e-Lab Result

From the Clinic Inbox, select the lab result to be stored and click View
1. If the lab result is systematically matched to a patient, the Patient section will be populated in the lab result display
2. If the lab result is not matched or the matched patient needs to be changed, the user will need to search for the patient
Optional: click Select to search for and select a patient
Select the I have verified the following lab results belong to the above patient checkbox
Click Sign/Route
Select the Sign checkbox and click OK

Stored e-Lab results can be viewed in the Flowsheets/Labs > Scanned/E-Labs tab of the patient chart.

eCQI Reference

https://ecqi.healthit.gov/ecqm/ec/2023/cms146v11

Return to 2023 eCQMs

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