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

Measurement Period: January 1–December 31.

Description: The percentage of episodes for persons 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic dispensing event.

Stratifications:

Ages as of the episode date.

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

Improvement Notation:
Increased score indicates improvement.

Note: Reported as an inverted rate [1–(numerator/denominator)].

A higher rate indicates appropriate treatment (i.e., the proportion of episodes that did not result in an antibiotic dispensing event).

Data Collection:

• Administrative.

Note: Supplemental data may not be used for this measure, except for denominator exclusions.

Initial Population:

• Measure Item Count: Episode.
• Age: 3 months of age or older as of the episode date.
• 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:

Episode date: The date of service for any outpatient, telephone or ED visit, e-visit or virtual check-in during the intake period with a diagnosis of URI.

Intake period: July 1 of the year prior to the measurement period to June 30 of the measurement period. The intake period captures eligible episodes of treatment.

Negative comorbid condition history: A period of 365 days prior to and including the episode date when the person had no claims/encounters with a diagnosis for a comorbid condition (366 days total).

Negative competing diagnosis: The episode date and 3 days following the episode date when the person had no claims/encounters with a competing diagnosis.

Negative medication history: To qualify for negative medication history, the following criteria must be met:

• A period of 30 days prior to the episode date when the person had no pharmacy claims for either new or refill prescriptions for a listed antibiotic drug.
• No prescriptions dispensed more than 30 days prior to the episode date that are active on the episode date.

A prescription is considered active if the “days supply” indicated on the date when the person was dispensed the prescription is the number of days or more between that date and the relevant service date. The 30-day look-back period for pharmacy data includes the 30 days prior to the intake period.

Denominator:
Episodes of upper respiratory infection diagnosis.

Persons who had an outpatient visit, ED visit telephone visit, e-visit or virtual check-in during the intake period, with a diagnosis of URI.

Note: The measure is based on episodes; therefore, it is possible for the denominator to include multiple events for the same person. If a person has more than one eligible episode in a 31-day period, only the first eligible episode will be included.

Numerator:
Antibiotic medication was dispensed.

Dispensed prescription for an antibiotic medication (AAB Antibiotic Medications List) on or 3 days after the episode date.

Best Practice and Measure Tips

This measure addresses appropriate treatment for upper respiratory infection. With strong adherence to evidence-based symptomatic care, patient education, precise coding, and diligent documentation, providers can ensure both high-quality clinical outcomes and excellent performance on the HEDIS Appropriate Treatment for URI measure.

Documentation for Quality Reporting

• Record strep test results or at least refusal.
• Use correct diagnosis code J00, J06.0, J06.9.
• Thoroughly document comorbidities, competing diagnoses, or active antibiotic use and, if appropriate, prescription of an antibiotic within three days of the test.

Education & Communication

• Clarify to patients the difference between viral and bacterial infections.
• Provide symptomatic relief guidance (rest, fluids, acetaminophen/NSAIDs, saline irrigation).

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.
• Exclude visits that result in an inpatient stay.
• Episode dates where the person had a claim/encounter with any diagnosis for a comorbid condition during the 365 days prior to or on the episode date.
• 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.
• Episode dates where the person had a claim/encounter with a competing diagnosis on or three 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, 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, B60.00, 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*

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, 92971000087109, 133171000119105, 10629231000119109, 10629271000119107

*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 Medications

AAB Antibiotic Medications List

• Amikacin
• Amoxicillin
• Amoxicillin / clavulanate
• Ampicillin
• Ampicillin / sulbactam
• Azithromycin
• Aztreonam
• Cefaclor
• Cefadroxil
• Cefazolin
• Cefdinir
• Cefepime
• Cefixime
• Cefotaxime
• Cefotetan
• Cefoxitin
• Cefpodoxime
• Cefprozil
• Ceftazidime
• Ceftriaxone
• Cefuroxime
• Cephalexin
• Chloramphenicol
• Ciprofloxacin
• Clarithromycin
• Clindamycin
• Dalfopristin / quinupristin
• Daptomycin
• Dicloxacillin
• Doxycycline
• Erythromycin
• Fosfomycin
• Gemifloxacin
• Gentamicin
• Levofloxacin
• Lincomycin
• Linezolid
• Metronidazole
• Minocycline
• Moxifloxacin
• Nafcillin
• Nitrofurantoin
• Nitrofurantoin, macrocrystals / nitrofurantoin, monohydrate
• Ofloxacin
• Oxacillin
• Penicillin g benzathine
• Penicillin g benzathine / penicillin g procaine
• Penicillin g potassium
• Penicillin g procaine
• Penicillin g sodium
• Penicillin v potassium
• Piperacillin / tazobactam
• Rifampin
• Streptomycin
• Sulfadiazine
• Sulfamethoxazole / trimethoprim
• Tetracycline
• Tobramycin
• Trimethoprim
• Vancomycin