For CMS 154, across stratifications, a denominator exclusion includes the following:

"Exclude URI episodes where the patient had competing diagnosis on or three days after the episode date."

This value set of competing diagnoses is: Competing Conditions for Respiratory Conditions OID 2.16.840.1.113883.3.464.1003.102.12.1017.

On review of a number of cases, we have found the following codes to not be included in this OID:

-Unspecified lymphadenitis I88.9 (though other lymphadenitis dx's are included)

-H65 codes for otitis media (though H66 codes are included), for example H65.191 and H65.01.

-J02.0 for strep pharyngitis and other strep pharyngitis codes

-This one is questionable, but SNOMED#128309002 for radiologic infiltrate may be considered for inclusion, as we see providers using this instead of a true pneumonia diagnosis when lung infiltrates are found on CXR - and treating these infiltrates (presumed pneumonia) with antibiotics.

We have seen all of the above diagnoses assigned in the same encounters as a diagnosis of viral URI, and antibiotics prescribed for the competing condition, but the encounter was not excluded from the measure since the condition was not included in the OID.  We recommend a review of the competing condition OID for its comprehensiveness, with attention to otitis media, strep pharyngitis, lymphadenitis, and pneumonia related encounters.