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Type: EC eCQMs - Eligible Clinicians
Resolution: Answered
Priority: Moderate
Component/s: None
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Thank you for your question regarding CMS154v11, Appropriate Treatment for Upper Respiratory Infection. Please see the responses to adding each code below.

J02.0 - Strep throat/Strep pharyngitis:
The measure intent is to include streptococcal pharyngitis as a competing diagnosis for CMS154 (URI). There is a code in the value set for "Streptococcal sore throat with scarlatina (disorder)" (SNOMED code 186357007) and therefore it is appropriate to map clinically equivalent diagnoses (e.g., J02.0 - Strep throat/Strep pharyngitis) to this code. If mapping is done, you should maintain documentation in case of a CMS audit. We will review the ICD10 codes and consider adding appropriate codes in the next possible measure publication (i.e., PY2025).

H60.91 - Recurrent otitis externa of right ear:
We do not include otitis “externa” in the measure because oral antibiotics are not indicated for otitis externa.

Z20.818 - Exposure to Streptococcal pharyngitis:
This code is not included because we do not believe that antibiotics are warranted for “exposure” to diseases. They are only warranted if person actually is positive for the disease (e.g., tests positive for strep).

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Thank you for your question regarding CMS154v11, Appropriate Treatment for Upper Respiratory Infection. Please see the responses to adding each code below. J02.0 - Strep throat/Strep pharyngitis: The measure intent is to include streptococcal pharyngitis as a competing diagnosis for CMS154 (URI). There is a code in the value set for "Streptococcal sore throat with scarlatina (disorder)" (SNOMED code 186357007) and therefore it is appropriate to map clinically equivalent diagnoses (e.g., J02.0 - Strep throat/Strep pharyngitis) to this code. If mapping is done, you should maintain documentation in case of a CMS audit. We will review the ICD10 codes and consider adding appropriate codes in the next possible measure publication (i.e., PY2025). H60.91 - Recurrent otitis externa of right ear: We do not include otitis “externa” in the measure because oral antibiotics are not indicated for otitis externa. Z20.818 - Exposure to Streptococcal pharyngitis: This code is not included because we do not believe that antibiotics are warranted for “exposure” to diseases. They are only warranted if person actually is positive for the disease (e.g., tests positive for strep).
2024 Performance Period EC eCQMs:

CMS0154v12
2023 Performance Period EC eCQMs:

CMS0154v11
Impact:

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In the past, the codes for strep throat and ear infections were included in the list of competing diagnoses or denominator exclusions when they were linked to an antibiotic order within three days of the URI diagnosis. Additional DENOMINATOR EXCLUSIONS when a patient prescribed or dispensed antibiotic for a documented medical reason(s) within three days included: 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.

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In the past, the codes for strep throat and ear infections were included in the list of competing diagnoses or denominator exclusions when they were linked to an antibiotic order within three days of the URI diagnosis. Additional DENOMINATOR EXCLUSIONS when a patient prescribed or dispensed antibiotic for a documented medical reason(s) within three days included: 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.

Regarding: CMS 154-Appropriate Treatment for Upper Respiratory Infection.
Please review the diagnosis and SNOMED codes related to DENOMINATOR EXCLUSIONS: Patient prescribed or dispensed antibiotic for a documented medical reason(s) within three days after the initial diagnosis of URI. In the past, the codes for strep throat and ear infections were included in the list of competing diagnoses or denominator exclusions when they were linked to an antibiotic order within three days of the URI diagnosis. Additional DENOMINATOR EXCLUSIONS when a patient prescribed or dispensed antibiotic for a documented medical reason(s) within three days included: 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.
Please see below for examples of ICD codes not mapped in the 2023 Value Data Set for denominator exclusion, but should be included:
J02.0 - Strep throat/Strep pharyngitis
H60.91 - Recurrent otitis externa of right ear
Z20.818 - Exposure to Streptococcal pharyngitis

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