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Appropriate Testing for Pharyngitis

EHP, Priority Partners, and USFHP. Members 3 years of age and older.

  • Percentage of episodes for members ages 3 years and older where the member was diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode.
  • A higher rate indicates appropriate testing and treatment.
  • Report three age stratifications and total rate:
    • 3–17 years.
    • 18–64 years.
    • 65 years and older.
    • Total. The total is the sum of the age stratifications

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.

Measure Exclusions

Required Exclusion: Hospice.

12 months prior to or on the episode date diagnosis of one of the below:

  • HIV
  • Malignant Neoplasms
  • Malignant Neoplasms of the Skin
  • Emphysema
  • COPD
  • Disorders of the Immune System

Measure Codes

  • Group A Strep Test
    • CPT/CPT II 87070-71, 87081, 87430, 87650-52, 87880
  • Pharyngitis ICD-10 Diagnosis
    • J02.0, J02.8, J02.9, J03.00, J03.01, J03.80-81, J03.90-91

Exclusion Codes Value Set:

  • COPD
    • J44.0, J44.1, J44.9
  • Emphysema
    • J43.0, J43.1, J43.2, J43.8, J43.9
  • Disorders of the immune system
    • D80.0-D81.2, D81.4 , D81.6, D81.7, D81.89, D81.9, D82.0-D82.4, D82.8, D82.9
  • HIV
    • B20, Z21
  • Malignant neoplasms
    • C00.0-C00.6, C00.8, C00.9, C01, C02.0-C02.4, C02.8, C02.9, C03.0, C03.1, C03.9, C04.0, C04.1, C04.8, C04.9, C05.0, C05.1, C05.2, C05.8, C05.9, C06.0, C06.1, C06.2, C06.80;
  • Other malignant neoplasms of the skin:
    • [C44.00] Unspecified malignant neoplasm of skin of lip
    • [C44.01] Basal cell carcinoma of skin of lip
    • [C44.02] Squamous cell carcinoma of skin of lip
    • [C44.90] Unspecified malignant neoplasm of skin, unspecified
    • [C44.91] Basal cell carcinoma of skin, unspecified
    • [C44.92] Squamous cell carcinoma of skin, unspecified
    • [C44.99] Other specified malignant neoplasm of skin, unspecified;
  • additional codes apply.

Measure Medications

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

  • Aminopenicillins
  • Amoxicillin
  • Ampicillin
  • Beta-lactamase inhibitors
  • Amoxicillin-clavulanate
  • First generation cephalosporins
  • Cefadroxil
  • Cefazolin
  • Cephalexin
  • Folate antagonist
  • Trimethoprim
  • Lincomycin derivatives
  • Clindamycin
  • Macrolides
  • Azithromycin
  • Clarithromycin
  • Erythromycin
  • Erythromycin ethylsuccinate
  • Erythromycin lactobionate
  • Erythromycin stearate
  • Natural penicillins
  • Penicillin G potassium
  • Penicillin G sodium
  • Penicillin V potassium
  • Penicillin G benzathine
  • Penicillinase resistant penicillins
  • Dicloxacillin
  • Quinolones
  • Ciprofloxacin
  • Levofloxacin
  • Moxifloxacin
  • Ofloxacin
  • Second generation cephalosporins
  • Cefaclor
  • Cefprozil
  • Cefuroxime
  • Sulfonamides
  • Sulfamethoxazole-trimethoprim
  • Tetracyclines
  • Doxycycline
  • Minocycline
  • Tetracycline
  • Third generation cephalosporins
  • Cefdinir
  • Cefditoren
  • Cefixime
  • Cefpodoxime
  • Ceftibuten
  • Ceftriaxone