CMS 154v12: Appropriate Treatment for Upper Respiratory Infection (URI)

Q: Numerator

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.

Updated June 8, 2026 4 minute read

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, online assessments (i.e., e-visit or virtual check-in), observation stays 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, online assessment, observation stay 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

Denominator

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

Encounter Codes Eligible for Denominator

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

Diagnosis

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

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

Denominator Exclusions

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

Hospice Care Services

Document Hospice Services as a Procedure

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: 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.

Document Hospice Services in the Assessment Tab

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

SNOMED CT: 305911006, 170935008, 170935009

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

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 comorbid conditions include tuberculosis and carcinoma.

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, G2250, G2251, G2252

Medication

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.

Encounter with Competing Condition

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.

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, G2250, G2251, G2252

Numerator

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.

eCQI Reference

https://ecqi.healthit.gov/ecqm/ec/2024/cms0154v12

Return to 2024 eCQMs