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Johns Hopkins Health Plans

CWP - Appropriate Testing for Pharyngitis

Product Lines:
Advantage MD, EHP, Priority Partners and USFHP.

Measurement Period: January 1–December 31.

Description:
Percentage of episodes for persons ages 3 years and older where the person was diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode.

Stratifications:
Ages as of the episode date.

  • 3–17 years.
  • 18–64 years.
  • 65 years and older.

Measure Reporting:
HealthChoice Performance Measure reporting for Priority Partners.

Improvement Notation:
Increased score indicates improvement.

Data Collection:

  • Administrative.
  • Supplemental.

Initial Population:

  • Measure Item Count: Episode.
  • Age: 1–4 years of age as of the last day of the measurement period.
  • Benefits: Medical and pharmacy.
  • Continuous Enrollment: 30 days prior to the episode date through 3 days after the episode date (34 total days).
  • Allowable gap: None.

 

Definition:  

Denominator:
Episodes of pharyngitis diagnosis where an antibiotic was dispensed.

  • Persons who had an outpatient, ED, telephone or e-visit or virtual check-in during the intake period with a diagnosis of pharyngitis.
  • Antibiotics (CWP Antibiotic Medications List) dispensed on or up to 3 days after the episode dates.

Note: The measure is based on episodes; therefore, it is possible for the denominator to include multiple events for the same person.

Numerator:
Group A streptococcus testing.
Episodes for which a group A streptococcus test occurred in the 7-day period from 3 days prior to the episode date through 3 days after the episode date.

Best Practice and Measure Tips

This measure addresses appropriate treatment for pharyngitis with a strep test and, if appropriate, prescription of an antibiotic within three days of the test.

A pharyngitis diagnosis can be from an outpatient visit, online assessment, telehealth visit, emergency department or observation visit between July 1 of the year prior to the measurement year and June 30 of the measurement year that did not result in an inpatient stay.

Measure Exclusions

Denominator Exclusions:

  • Persons in hospice or using hospice services any time during the measurement period.
  • Persons who died any time during the measurement period.
  • 12 months prior to or on the episode date diagnosis of Comorbid Conditions.
  • Episode dates where a new or refill prescription for an antibiotic medication was dispensed 30 days prior to the episode date or was active on the episode date.
  • Persons who had a claim/encounter with a competing diagnosis on or 3 days after the episode date.

Exclusion Codes

  • Comorbid Conditions
    • ICD-10-CM: A15.0, A17.0, A18.01, A19.0, B44.81, D57.01, D61.810, D70.0, D71, D72.0, D75.81, D76.1, D86.0, E84.0, J22, J41.0, J42, J47.0, J60, J61, J62.0, J63.0, J64, J65, J66.0, J67.0, J68.0, J69.0, J70.0, J80, J81.0, J82, J84.01, J85.0, J86.0, J90, J91.0, J92.0, J93.0, J94.0, J95.00, J95.01, J96.00, J98.51, J99, M05.10, M30.1, M32.13, M33.01, M34.81, M35.02, O98.011, P27.0, Q25.45, Q30.0, Q31.0, Q32.0, Q33.0, Q34.0, Q34.1, Q39.0, Q89.01*
  • Competing Diagnosis
    • ICD-10-CM: A00.0, A02.0, A03.0, A04.0, A05.0, A06.0, A07.0, A08.0, A09, A37.00, A44.0, A50.01, A54.00, A55, A56.00, A57, A58, A59.00, A59.9, A63.0, A64, A69.0, A69.9, B60.0, B64, B78.1, B96.89, E83.2, H66.001, H67.1, H70.001, H95.00, J01.00, J04.10, J05.0, J13, J14, J15.0, J16.0, J17, J18.0, J20.0, J32.0, J35.01, J38.7, J39.0, K05.20, K12.2, L01.00, L03.011, L04.0, L08.1, L92.8, L98.0, M46.20, M89.00, M90.80, N10, N12, N13.0, N15.1, N16, N30.00, N39.0, N41.0, N70.01, N71.0, N72, N73.0, N74, N75.0, N76.0, N77.0, Z20.2, Z22.4

*Please note that not all ICD-10-CM and SNOMED CT US Edition codes are listed here. For access to the complete set of codes related to Comorbid Conditions and Competing Diagnosis Value Set, contact your Provider Engagement Liaison or email [email protected].

Measure Codes

Group A Strep Test

  • CPT: 87070, 87071, 87081, 87430, 87650, 87651, 87652, 87880
  • LOINC: 17898-8, 626-2, 17656-0, 11268-0, 31971-5, 6558-1, 6559-9, 18481-2, 6557-3, 78012-2, 49610-9, 103627-6, 101300-2, 60489-2, 5036-9, 68954-7, 105062-4, 105063-2

Pharyngitis

  • ICD-10-CM: J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91
  • SNOMED CT US Edition: 140004, 652005, 1532007, 2365002, 10351008, 11461005, 14465002, 17741008, 27878001, 31309002, 39271004, 40766000, 41582007, 43878008, 51209006, 55355000, 58031004, 59471009, 63866002, 72430001, 76651006, 78430008, 78911000, 82228008, 87326000, 90176007, 90979004, 95885008, 111816002, 126664009, 126665005, 186357007, 186659004, 186963008, 195655000, 195656004, 195657008, 195658003, 195659006, 195660001, 195662009, 195663004, 195666007, 195667003, 195668008, 195669000, 195670004, 195671000, 195672007, 195673002, 195676005, 195677001, 195709006, 195779005, 195780008, 195782000, 195803003, 195804009, 195924009, 232399005, 232400003, 232401004, 232402006, 232403001, 232405008, 232406009, 232417005, 240444009, 240547000, 302911003, 312422001, 363746003, 405737000, 415724006, 703468005, 721586007, 878818001, 1296672005, 133171000119105, 10629231000119109, 1062927100011910

Measure Medications

The following antibiotic medications, in conjunction with a strep test, will meet compliance for this measure:

CWP Antibiotic Medications

  • Amoxicillin
  • Amoxicillin-clavulanate
  • Ampicillin
  • Azithromycin
  • Cefaclor
  • Cefadroxil
  • Cefazolin
  • Cefdinir
  • Cefixime
  • Cefpodoxime
  • Cefprozil
  • Ceftriaxone
  • Cefuroxime
  • Cephalexin
  • Ciprofloxacin
  • Clarithromycin
  • Clindamycin
  • Doxycycline
  • Erythromycin
  • Levofloxacin
  • Minocycline
  • Moxifloxacin
  • Ofloxacin
  • Penicillin G Benzathine
  • Penicillin G Potassium
  • Penicillin G Sodium
  • Penicillin V Potassium
  • Sulfamethoxazole-trimethoprim
  • Tetracycline
  • Trimethoprim