CMS 146v12: 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 on or three days after the episode date 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 from January 1 to December 28 of the measurement period and an antibiotic order on or three 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:

  • Pharyngitis episodes when the patient had hospice care for any part of the measurement period

  • Pharyngitis episodes where the patient had a comorbid condition during the 12 months prior to or on the episode date

  • Pharyngitis episodes where the patient is taking antibiotics in the 30 days prior to the episode date

  • Pharyngitis episodes where the patient had a competing diagnosis on or three days after the episode date

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.

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 from January 1 to December 28 of the Measurement Period finalized by the EC

    AND

  • Have an antibiotic prescribed on the day of the eligible encounter or 3 days after the encounter

CPT: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 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, 98980, 98981, 99444, 99457

HCPCS: G0071, G2010, G2012, G2061, G2062, G2063, G2250, G2251, G2252

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

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

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

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

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.

The eligible diagnosis codes for Hospice Services are only available as SNOMED CT codes.

SNOMED CT: 305911006, 170935008

SNOMED codes can be added in the Assessment tab by mapping the code to an active ICD-10 using the Map SNO button.

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 comorbid conditions include tuberculosis and atelectasis.

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

CPT: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 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, 98980, 98981, 99444, 99457

HCPCS: G0071, G2010, G2012, G2061, G2062, G2063, G2250, G2251, G2252

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

A patient with an active diagnosis for a competing condition—assessed on or 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 competing conditions include otitis media, sinusitis, and pneumonia.

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

CPT: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 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, 98980, 98981, 99444, 99457

HCPCS: G0071, G2010, G2012, G2061, G2062, G2063, G2250, G2251, G2252

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.

  1. 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
  2. Optional: click Select to search for and select a patient
  3. Select the I have verified the following lab results belong to the above patient checkbox
  4. Click Sign/Route
  5. 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.

https://ecqi.healthit.gov/ecqm/ec/2024/cms0146v12

 

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