CMS 154v13: Appropriate Treatment for Upper Respiratory Infection (URI)

Measure: Percentage of episodes for patients 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic order
Measure Type High Priority Measure Scoring
Process Yes A higher percentage indicates better quality
Denominator Outpatient visits, telephone visits, virtual encounter (i.e., e-visit or virtual check-in), or emergency department visits with a diagnosis of URI from January 1 to December 28 of the measurement period for patients 3 months of age and older
Numerator URI episodes without a prescription for antibiotic medication on or three days after the outpatient visit, telephone visit, virtual encounter, or emergency department visit for an upper respiratory infection
Denominator Exceptions None
Denominator Exclusions

Exclude:

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

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

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

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

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

  • Age is ≥ 3 months at the beginning of the Measurement Period

    AND

  • Have at least one eligible encounter with a diagnosis of URI from January 1 to December 28 of the Measurement Period finalized by the EC

CPT: 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 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, 98970, 98971, 98972, 99421, 99422, 99423, 99458, 98980, 98981, 99457

HCPCS: G0071, G2010, G2012, G2250, G2251, G2252

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

ICD-10: J00, J06.0, J06.9

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.

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 carcinoma.

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: 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 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, 98970, 98971, 98972, 99421, 99422, 99423, 99458, 98980, 98981, 99457

HCPCS: G0071, G2010, G2012, 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 tonsillitis, 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: 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 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, 98970, 98971, 98972, 99421, 99422, 99423, 99458, 98980, 98981, 99457

HCPCS: G0071, G2010, G2012, G2250, G2251, G2252

A patient will be counted in the numerator if they did not receive a prescription for antibiotic medication on or three days after their eligible encounter.

A comprehensive list of antibiotic medications that, if prescribed, will exclude the patient from the numerator can be located here.

https://ecqi.healthit.gov/ecqm/ec/2025/cms0154v13

 

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